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Patient Satisfaction: Communication with NursesCathy C. OniRegis University
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Recommended CitationOni, Cathy C., "Patient Satisfaction: Communication with Nurses" (2012). All Regis University Theses. 165.https://epublications.regis.edu/theses/165
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Doctor of Nursing Practice
Patient Satisfaction: Communication with Nurses
Cathy C. Oni
Submitted in partial fulfillment for Doctor of Nursing Practice Degree
Regis University
April 9, 2012
i
Copyright © 2012 Cathy C. Oni
All rights reserved. Contents of this work may not be reproduced, stored in a retrieval system, or
transmitted, in any form, or by any means, electronic, mechanical, photocopying, recording or otherwise,
without the author’s prior written permission.
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EXECUTIVE SUMMARY
Patient Satisfaction: Communication with Nurses
Problem
Patient satisfaction is a pivotal issue within the healthcare industry. Hospital Consumer Assessment of Healthcare Provider and System (HCAHPS) survey clearly states that patient response to this survey is the indicator for “quality of care” (Wagner & Bear, 2008, p. 692). A patient may equate quality of care to the manner in which it was delivered; hence when unsatisfied with their care, the patient may translate this into negative feedback on HCAHPS surveys (Lo, Burman, Rodin, & Zimmermann, 2009). Communication with Nurses is one of the domains in HCAHPS survey that is scoring low percentage in patient satisfaction. Nevertheless, an important element to experiment for this issue would be staff education. Based on this domain [Communication with Nurses], a PICO (Population, Intervention, Comparison, Outcome) question was developed to direct the focus of intervention that could help in addressing the issues of patients’ perception toward communication with nurses. The PICO question was: In an acute care hospital in the Houston Medical Center on a 29 bed medical unit, will there be an increase in patient satisfaction scores as a result of improved staff level of communication?
Purpose
This quality improvement project focuses on determining effective interventions that will improve nurses’ communication skill, improve nurse-patient interaction, and increase patient satisfaction scores as indicated by HCAHPS survey.
Goals The goal for this project was to improve staff communication skill, nurse-patient interaction, and increase patient satisfaction as evidenced by the HCAHPS survey target scores at the threshold (77.4%) or on target (78.4%).
Objectives
The objectives for this project include 1) Increase staff level of communication knowledge and skill. 2) Increase patient satisfaction as indicated by HCAHPS survey scores at threshold (77.4%) or target (78.4%).
Plan
The project began with identification of the needs and extensive literature review for evidence-based information. This was followed by identification of the population, sponsor and stakeholders, the organization, resources, a determination of desired outcomes, team selection, cost/benefit analysis, and development of the scope of the project. The Institution Review Board (IRB) and Research Council Committee approval was obtained from Regis University and the clinical site respectively. The project was implemented in four phases: Pre-intervention data collection to acquire a baseline, Implementation of Intervention [staff education on how to conduct purposeful hourly rounding], Post-intervention data collection to assess staff compliance, and Evaluation of the outcomes.
Outcomes
Thirty one (31) health care providers participated in the education session. Analysis of the data collected pre- and post-intervention from the HCAHPS survey indicates a significant increase in the patient satisfaction scores from 68.5% to 93%.
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Acknowledgement
This author acknowledges the following: The Methodist Hospital at Houston Medical Center
(Houston TX) and the staff in the Medical Unit. The author also wants to acknowledge Heather Chung
PhD, RN (Director of the Medical Unit at The Methodist Hospital, Houston Medical Center) for her
mentoring and guidance throughout the project; Pam Green, MSN, RN (Manager of the Medical Unit at
The Methodist Hospital, Houston Medical Center) for her assistance in data collection; Brenda Case-
Cook, MSN, RN, for her support; Margaret Oni, MD, for her support; Emmanuel Oni, BS, and John Oni,
BS, for data entry and Electronic Technical support. Finally, the author acknowledges the Professors at
Regis University Doctor of Nursing Practice (DNP) degree program (Loretto Heights School of Nursing,
Regis University).
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Table of Contents
Page Copyright...………………………………………………………………………………………………….i Executive Summary..………………………………………………………………………………….…....ii Acknowledgement .………………………………………………………………………………………..iii List of Table ……………………………………………………………………………………………….vi List of Figures……………………………………………………………………………………………..vii List of Appendices………………………………………………………………………………………..viii Problem Recognition and Definition
Statement of Purpose.... ……………………………………………………………………………...1 Problem Statement ……..………………………………………………………………………........2 Study Question .…………..………………………………………………………………………….2 PICO..……………………………………………………………………………………………...2 Project Significance, Scope, and Rationale ……………………………………………….................2 Theoretical Foundation ………………………………………………………………………….......3 Literature Selection ………………………………………………………………………………….3 Scope of Evidence ……………………………………………………………………………….......3
Review of Evidence Background of the Problem ……………………………………………………………………….4 Literature Review …………………………………………………………………………………5
Effect of Rounding ………………………………………………………………..............5 Proactive Rounding ……………………………………………………………….............5 Use of Call Bell …………………………………………………………………………...5 Indicator for Caring ...……………………………………………………………..............6 Evaluation of an Integrated Communication Skills Training ………………………….....6 Project Plan and Evaluation Market/Risk analyses ……………………………………………………………………………...7 Project Strengths, Weaknesses, Opportunities, Threats …………………………………………...7 Driving/Restraining Forces ………………………………………………………………..............8 Project Needs ……………………………………………………………………………………...9 Project Resources ………………………………………………………………………….............9 Project Sustainability ……………………………………………………………………………...9 Feasibility/Risks/Unintended Consequences ……………………………………………………..9
Stakeholders and Project Team …………………………………………………………………..10 Stakeholders ……………………………………………………………………………..10 Project Team …………………………………………………………………………….10 Cost-benefit analysis ……………………………………………………………………………..10 Mission ……………………………………………………………………………………...........12 Vision……………………………………………………………………………………………..12 Goals ………………………………………………………………………………………..........13 Process/Outcomes objectives outlined ……………………………………………………...........13 Process Objectives ………………………………………………………………………13 Outcome Objectives ……………………………………………………………………..14 Logic Model ……………………….. ……………………………………………………………14 Population/Sampling Parameter …………………………………………………………………14 Project Setting ……………………………………………………………………………………15 Project Design ……………………………………………………………………………………15 Methodology……………………………………………………………………………………...15 Measurement …………………………….. ………………………………………………...........16 Protection of Human Rights ………………………………………………………………...........16
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Page Instrumentation Reliability/Validity and Intended Statistics …………………………………....16
Reliability and Validity ……………………………………………………………........16 Intended Statistics ……………………………………………………………………....17 Data Collection and Treatment Procedure/Protocol ……………….…………………………....17
Pre-Intervention Phase ………………………………………………………………….17 Intervention Phase ………………………………………………………………………17 Post-Intervention Phase …………………………………………………………………19 Project Findings and Results Project Findings ...……………………………………………………………………………......20 Analysis of Intervention………………………………………………………………….21 Project Outcomes Results ……………………………………………………………………… 24 Limitation, Recommendation, Implication for Change Limitation …………………………………………………………………………………...........25 Recommendation ………………………………………………………………………………...25 Nursing ………………………………………………………………………………......25 Nursing Theory ……………………………………………………………………….....26 Research ………………………………………………………………………………....26 Advanced Practice/Leadership Education ……………………………………………....26 Health Policy …………………………………………………………………………….26 Implication for Change …………………………………………………………………………..26 Nursing ………………………………………………………………………………….26 Hospital ………………………………………………………………………………….26 Patients …………………………………………………………………………………..26 Conclusion …………………………………………………………………………………………..........27 References ………………………………………………………………………………………………...28
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List of Tables
Page Table 1: PICO.……………………………………………………………………………………………...2 Table 2: SWOT Analysis………...…………………………………………………………………………8 Table 3: Project Cost-Benefit Analysis …………………………………………………………………...11 Table 4: Principal Investigator’s Costs & Funds ………………………………………………................12 Table 5: Process Objectives ……………………………………………………………………................13 Table 6: Demographic Data Analysis …………………………………………………………………….21 Table 7: Changes in Communication Skill ……………………………………………………………….23 Table 8- Changes by Years of Practice..…………………………………………………………………..24
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List of Figures
Page Figure 1: Pre- & Post-Intervention Questionnaire Result……….………………………………………...18 Figure 2: Outcome #4 – Hourly rounding log Means per day………....…….…………………………...19 Figure 3: Data Collection & Treatment Procedure/Protocol……………………………………………...20 Figure 4: Pre- & Post-Intervention HCAPS Survey Scores……….. …………………………………….25
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List of Appendices Page
A. 10 Conceptual Curative Factors…………………………………………………………….................32 B. Systematic Literature Review…..……………………………………………………………………..33 C. Logic Models.….. ……………………………………………………………………………………66 D. Conceptual Diagram ………………………………………………………………………………….67 E. Measurement tool/Instrument E.1. Communication Tool: Rounding Checklist………..…………………………………...........68 E.2. Hourly Rounding Log………..…………………………………………………………........69 E.3. Pre- & Post-Intervention Questionnaire………...……………………………………….......70 E.4. Demographic data form………. .……………………………………………………………71 E.5. Staff Education/In-services Schedule………. ...…………………………………………….72 F. Timeframe F.1. Project Implementation Timeline Chart 2011. .…...………………………………………73 F.2. Capstone Project Timeline Table 2011-2012 ……………………………….........................74 F.3. Capstone Project Timeline Chart 2011-2012….…………………………….........................76 G. Budget and Resources G.1. Capstone Project Budget (Estimated Cost)…………………………………….....................77 G.2. Project Cost/Funds………………………………………………………………..................77 H. Regis University IRB approval Letter…………………………………………………………………78 I. CITI Training Certificate I.1. Regis University………….………………………………………………………..................79 I.2. The Methodist Hospital System…………………………………………………...................80 J. Agency Letters of Support to complete the project .……...…………………………………………….81
1
Patient Satisfaction: Communication with Nurses
Professional caretakers are very passionate about the care given to their patients. Their intent is
to see that patients experience the love and care they deserve so they may reach their potential goals.
However, guidance and direction may be necessary to improve how they interact with patients and it was
an area this project attempted to address. “Satisfaction with nursing services is the only hospital services
identified as having a direct relationship with overall patient satisfaction” (Wagner & Bear, 2008, p.693).
Nurses may have good intentions in caring for their patients; however, not communicating the plan of
care, not attending to their needs, and ineffective patient-nurse interaction could be a potential hindrance
to patient-nurse communication.
Problem Recognition and Definition
Patient satisfaction is a pivotal issue within the healthcare industry. Hospital Consumer
Assessment of Healthcare Provider and System (HCAHPS) survey clearly states that patient response to
surveys is the indicator for “quality of care” (Wagner & Bear, 2008, p. 692). HCAHPS survey indicates
low scores in Communication with Nurses domain for patient satisfaction in the study unit. A patient
may equate quality of care to the manner in which it was delivered; hence when unsatisfied with their
care, the patient may translate this into negative feedback on HCAHPS surveys (Lo, Burman, Rodin, &
Zimmermann, 2009). It was anticipated that educating nurses and the ancillary staff in the area of
communication would maximize their ability to interact with patients effectively (Jha, A. K. Orav, E. J.,
Zheng, J., & Epstein, A. M., 2008).
Upon recognition of this issue, a project timeline was formulated to direct the plan and
implementation of the intended intervention. Appendix F.1 indicates project implementation timeline
chart (January to April 2012). Appendix F.2 (Capstone Project Timeline, January 2011 to April 2012)
depicted the nine steps initiated in this project, and Appendix F.3 displays the project timeline from the
start to the end (from January 2011 to April 2012). Although all attempts were made to follow this
timeline as planned, constraints such as obtaining Institutional Review Board (IRB) approval delayed
project progression. Nevertheless, the project was conducted to completion in a timely manner.
Statement of purpose. This quality improvement project focused on determining effective
interventions that would improve nurses’ communication skill, improve nurse-patient interaction, and
increase patient satisfaction scores as indicated by HCAHPS survey. Patient satisfaction is defined as
“the degree to which nursing care meet patients’ expectations in terms of art of caring, technical quality,
physical environment, availability and continuity of care, and the efficacy/outcome of care” (Mrayyan,
2006, as cited in Wagner & Bear, 2008, p. 693). Based on the HCAHPS domain for Communication
with Nurses, a PICO (Population, Intervention, Comparison, and Outcome) question was developed as
2
indicated below (Table 1) to direct the focus of intervention that could help address patient-nurse
communication.
Problem statement. The issue of patient satisfaction as related to communication with nurses
has become a universal problem in healthcare organizations across the country. The nursing domain in
the HCAHPS survey asked patients the following questions: “Nurses always treated you with courtesy
and respect”; “Nurses always listened carefully to you”; and “Nurses always explained things in a way
you could understand” (Center for Medicare & Medicaid Services, HCAHPS Quality Assurance
Guideline, 2012, p. 189). Patients answered these questions based on their perception of the type of care
they received during the period of their hospitalization (Wagner & Bear, 2008).
PICO/study question. In an acute care hospital in the Houston Medical Center on a 29 bed
medical unit, will there be an increase in patient satisfaction scores as a result of improved staff level of
communication?
Table 1: PICO
P – Population Registered Nurses (RN), Patient Care Assistants (PCA) and the Unit Secretaries (US) in an acute care hospital in the Houston Medical Center on a 29 bed medical unit.
I – Intervention Education on Communication • Video: Heart-Head-Heart Concept (Leebov, 2011) • 4Ps (pain, position, potty, & placement) (Woodward, 2009) • AIDET concept – Acknowledge, Introduction, Duration, Explanation, Thanks (Studer Group, 2011) [Reflecting Jean Watson’s Theory of caring] • Questionnaire • Communication Tool • Hourly Rounding
C – Comparison Beginning Hospital Consumer Assessment of Healthcare System (HCAHPS) survey scores of 68.5%
O – Outcome Improved Patient Satisfaction scores as indicated by the Hospital Consumer Assessment of Healthcare Provider and System (HCAHPS) survey scores (between 77.4% and 78.4%)
Project significance, scope, and rationale. Patient satisfaction is a matter of urgency for many
health care institutions today. In part, this is due to the regulatory requirements and penalties that will be
imposed if health care institutions fail to meet required “quality measure” (HCAHPS Fact sheet, 2010,
Para. 6) in the HCAHPS survey. As previously stated, patient satisfaction is now considered an
important measure for quality of care. Therefore, the significance of this project was to improve staff
communication skill, improve nurse-patient interaction, and prevent loss of reimbursement. The scope
3
was to evaluate Hospital Medical Unit staff communication skills, implement education that can improve
staff communication skill, indicate findings, and identify changes. The rationale behind this project was
finding an effective and efficient intervention to improve staff communication skills and patient-nurse
interaction, which would ultimately enhance patient satisfaction.
Theoretical foundation. The supporting theory for this project was Jean Watson’s theory of
human caring (Tomey & Alligood, 2006). Jean Watson is one of the most prominent caring theorists; she
“defines caring as a science” (Vance, 2003, Para. 2) of care. Pipe (2006) illustrates the benefit of Human
Caring theory by associating it with “patient-centered caring behaviors, communication, and patient
safety” (p.234). In consideration of these, it became clear that in order to effectively implement the
proposed intervention (education), it would be best to apply the concepts of human caring theory. Some
of the criteria taken into consideration in the process of selecting this theory included comfort, safety, and
inclusion of patients in their care. Jean Watson’s theory of human caring provided guidelines for its
application through the ten “Carative Factors” (Tomey & Alligood, p. 104). These factors are listed in
Appendix A. These factors portray the importance of providing an injury free environment which,
coincidently, is one of the focuses of hourly rounding. For example, a particular concept that has a direct
connection to the issue of patient satisfaction is “transpersonal caring relationship” (Tomey & Alligood,
p. 103), which indicated delivery of wholeness caring, connectedness to the patients’ world, and
exhibition of moments of compassionate caring (Tomey & Alligood, 2006). These concepts had a direct
relationship to the development of communication skills and effective nurse-patient interactions. They
were also embedded into how to perform a purposeful hourly rounding (Meade, Bursell, Ketelsen, 2006).
Literature Selection. This process includes the application of key words in search for related
articles/literatures in order to collect evidence-based information to guide the project. These key words
included but were not limited to patient satisfaction, patient safety, nursing care, call light, hourly
rounding, caring, and education. Data-bases searched included CINAHL, Academic Search Premier,
Ovid, Medline, and PubMed.
Scope of evidence. There were eight level I (one) evidence articles, which focused on Evidence-
Based Practice (EBP) guidelines, two level II (two) evidence articles that focused on randomized trials
with small to moderate sample sizes, fourteen level III (three) non-randomization but well-designed trials,
and six level IV (four) articles, which dealt with descriptive studies (Houser & Oman, 2011). The
predominant emphasis in these articles were gap analysis, measurement for patient satisfaction and safety,
intervention, studies on hourly rounding, and evaluation.
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Review of Evidence
Background
In recent years it has become clear that patients were becoming more involved in their care and
the healthcare system had been favoring patient-centered care as well. Hence, the issue of patient
satisfaction can be directly related to patient involvement in their care (patient-centered care). It was
noted in the “Measurement of Patient Satisfaction Guidelines” compiled by the Irish Society for Quality
and Safety in Healthcare (2003) that patients’ participation in the decision-making processes in their care
could “leads to improvement in healthcare outcome” (p. 9). Furthermore, being able to understand the
patient’s perception about their care helped organization and staff to be aware of patients’ discontent. A
standardized approach to measuring patient satisfaction could help in the assessment of organization and
individual accountability. Patients’ perception of their care depended on their experience; therefore,
patients’ feedback could help to influence quality improvement.
In 1994, Joint Commission on Accreditation of Health Care Organizations (JACHO) required
patient satisfaction as one of the standards for accreditation (Irish Society for Quality and Safety in
Healthcare, 2003). In 2002 the need for national standardization of measuring patient satisfaction led to
the Medicare/Medicaid Services (CMS) and Agency for Healthcare Research and Quality (AHRQ)
initiation of HCAHPS development and was approved in 2005 by the National Quality Forum (HCAHPS
Fact Sheet, 2010).
Delivering effective and satisfactory care is the ultimate goal of healthcare organizations. Hence,
the role of nursing cannot be underestimated. Tools for measuring patient satisfaction were first
introduced by Abdellah and Levine (as cited in Wagner & Bear, 2008); however, this initial survey did
not include nursing evaluation. As a result, Risser (as cited in Wagner & Bear) introduced another tool
that included patient-nurse interaction that contributed to patient care. Both tools validated quality of care
as the main contributor to increasing patient satisfaction. Hinshaw and Atwood (1981) stated that
patients’ perception of satisfaction was based on the “care” given by the “nursing staff” (as cited in
Wagner & Bear, p. 693). Furthermore, patient satisfaction was defined by Mrayyan “as the degree to
which nursing care meets patients’ expectations in terms of art of caring, technical quality, physical
environment, availability and continuity of care, and the efficacy/outcomes of care” (as cited in Wagner
& Bear, p. 693).
Recently, Medicare/Medicaid has mandated healthcare organizations to meet certain requirements
in HCAHPS surveys; otherwise a certain percentage of reimbursement would be withheld (Kutney-Lee, et
al., 2009). Nurses were the first contact with patients and, as a result, their role had become very crucial
in the process of achieving acceptable patient satisfaction scores. Therefore, impressive nurse-patient
communication was necessary.
5
Kutney-Lee, et al. (2009) concluded in their cross-sectional study that the effect of nursing in
patient satisfaction should not be underestimated. Nursing is the catalyst that can turn around patient
satisfaction. Larrabee, et al. (2004) indicated in their study that “the major predictor of patient
satisfaction” (p.255) was patients’ perception towards the nursing care they received. Another study
conducted by Henderson, et al. (2007) revealed that communication with nurses carried a substantial
weight in the process of achieving high patient satisfaction scores. They concluded that patients desire an
explanation for unmet needs and are eager to learn more about their plan of care.
Literature Review
Numerous articles and research studies have been conducted by experts related to the issue of
patient satisfaction. In order to develop a substantive educational tool that will improve patient
satisfaction as associated with communication with nurses, a systematic literature review was conducted
(Appendix B). The following studies were also reviewed and analyzed.
Effect of rounding. Woodward (2009) conducted a study on implementation of “patient
rounding” (p. 200) that focused on patient satisfaction and safety. The study supported the notion that
rounding gives patients the assurance that someone will be checking on them periodically. Thus, instead
of attempting to use the call light or ambulate to the bathroom without assistance, they may choose to
wait until staff rounding time. The intervention was implemented with the charge nurse making routine
rounds at two hour intervals, focusing on the “4Ps… [pain, position, potty, and placement]” (p. 200). At
the conclusion of the study, it was indicated that there was a significant increase in patient satisfaction,
reduction in patients’ use of the call light, and a decrease in falls.
Proactive rounding. According to Tea, Ellison, and Feghali (2008), a study was conducted on
an orthopedic unit focusing on “improving …staff responsiveness to patients’ needs and requests” (p.
233). Approximately 40,000 responses from patients were analyzed and it was reported that the main
determinant of patient satisfaction was “timely response” (Tea, et al. p. 233) to patient calls and needs.
Gap analysis was conducted in order to determine the solution to this issue. A model was formulated
focusing on how to perform effective hourly rounding. The model was implemented in an orthopedic unit
with a script for the staff to utilize as they performed their hourly rounding. A rounding form was also
formulated for the nursing leaders to measure the effectiveness of the model. At the conclusion of the
study, an improvement in patient satisfaction was noted.
Use of call bell. Torres (2007) indicated that patient satisfaction was a “nurse sensitive indicator”
(p. 480). The study focused on relating “quality of care” (as cited in Wagner & Bear, 2008, p. 692) to
nursing practice. Patients’ perception of their care was reflected in the patient satisfaction survey;
therefore, it was necessary to educate the staff regarding the relationship between the care they give and
the patients’ perception of the care received. A call light log was utilized to identify the most important
6
reasons for patients’ calls. It was discovered that the need for reposition, pain, and toileting were the top
three requests, which were referred to as “predictable call bell use” (Torres, p. 481). The strategic
solution was the introduction of hourly or two-hourly rounding schedule and proactively offers pain
medication, blankets, and assistant for toileting. The result was a significant decrease in patients’ use of
call light.
Indicator for caring. This qualitative study with descriptive statistics focused on evaluating the
nurse-patient interactions and patients’ perception towards “these interactions” (Henderson, et al., 2007,
p.146). Observation and questionnaires were utilized to collect data. It was emphasized in this article
that when patients were not satisfied with the mode of delivery of care, the tendency to complain was
actualized. At the conclusion of the study, the primary finding was that positive nurse-patient interactions
portray caring. Management of activities of daily living (ADL) routinely and explaining
technical/medical aspects of patient care gave the patient a positive concept of how knowledgeable the
nurses were on the unit. Additionally, patients’ expectations included prompt response to their requests
and knowing whether their requests could be met. The authors concluded that nurses should adopt such
procedures as introducing themselves when they walked into the patient’s room, communicating to the
patients their plan of care, and prioritizing or managing their duties in an effective manner.
Evaluation of an Integrated Communication Skills Training
A quasi-experimental study was conducted with a “nonequivalent control group” (Liu, et al.,
2007, p. 203). A total of 129 Registered Nurses participated in the study. Education sessions were given
in association with practical use of the learning skill in the designated units. The study was conducted
over five months. Evaluation of the effectiveness of the training was conducted. The outcome of the
intervention was positive; the nurses “basic communication skill” (Liu, et al., p. 203) improved
significantly in the experimental group. No improvement was noted in the control group. The outcomes
of this study essentially supported the use of education to improve nurses’ knowledge of communication.
Based on the outcomes of these studies, it appeared that communication was the key to gaining
patients’ positive perception toward nurses’ interactions. If patients were effectively informed of their
plan of care, it would be easier for them to adjust or comply with their treatment regimen, promoting
speedy recovery and reducing length of stay (LOS). All of these actions could eventually lead to
improved patient satisfaction. Additionally, it was clear that nurses were the primary channel through
which patient satisfaction could be achieved. Educating nursing staff regarding effective communication
with their patients could pave the way for a positive nurse-patient interaction.
7
Project Plan and Evaluation
Market/Risk Analysis
The market/risk analysis was conducted to evaluate the project Strengths and Weaknesses,
Opportunities, and Threats.
Project strengths and weaknesses. Strengths were drawn from well experienced and
knowledgeable individuals (Mentor, Chairperson, Advisor, Course Instructors, and Statistician) who have
acquired doctorate degrees in their respective fields. They also have conducted numerous research
studies in the past; therefore, they brought a wealth of knowledge into the project. The project was
conducted at a medical center in one of the well-respected hospitals involved in various research projects.
Additionally, this project was resourceful to the staff in the Medical Unit because it provided evidence-
based information, and the team members were able to analyze the Medical Unit needs for quality
improvement and provide advice based on outcome. Weaknesses in this project included limited
resources, limited time, small sample size, and determining long term retention and application of
education contents, and untested tools for the intervention (questionnaire and demographic contents were
self-developed).
Opportunities. The project was implemented at the time many of the health care providers were
struggling to meet the regulatory entities’ requirements for patient satisfaction. However, modern
technology made it potentially easier to meet the need for quality improvement, improved staff
communication skill, and increased patient satisfaction. This project would also allow hospital systems to
meet their target as required by Medicare/Medicaid and other third-party payers.
Threats. There were few potential threats to this project, which included the process of receiving
an approval to conduct the project at the acute care facility. Although it took a lengthy process to obtain
final approval (Appendix H and J), the IRB at Regis University and the Research Council Committee at
the hospital where the project was conducted reviewed the project to ensure that it met their requirement.
Missing or incomplete data could also pose a threat to the validity and reliability of the project outcome.
Using this SWOT analysis, the following table depicts a snapshot of the project’s strengths, weaknesses,
opportunities, and threats (Fortenberry, 2010).
8
Table 2: SWOT Analysis
Project SWOT Analysis
Strengths Weaknesses Location
• Medical Center Qualifications
• Principal Investigator – RN, MSN, Certified Healthcare Educator, Doctor of Nursing Practice candidate (DNPc)
• Mentor – PhD, RN, Experienced Researcher
• Project Chairperson – Doctorate Degree, Educator
• Advisor – Doctorate Degree, Educator • Course Instructors – Doctorate Degree,
Educators
Resourceful to the Staff • Provide evidence-based information • Ability to analyze the Medical Unit needs
for quality improvement and advise based on project outcome
Limited resources Limited time Small sample size Determining long-term retention of education contents Untested tools for the intervention (Questionnaire & Demographic contents were self-developed)
Opportunities Threats • Technology • Quality Improvement • Improve staff communication skill • Increase patient satisfaction
• Regulatory Entities requirement • Research regulations • Institutional Research Board (IRB) • Possible missing or incomplete data • Staff resistance to change
The hospitals’ and clinics’ administrative leaders, physicians, and nurses were essential resources
for achieving an acceptable patient satisfaction score. These were the community of professionals needed
for collaborative effort to successfully accomplish the goal of quality improvement. Moreover, the
Director of the Medical Unit where this project was conducted has access to the Heart-Head-Heart video.
This promoted sustainability of the intervention and introduced new employees to effective and efficient
communication skills.
Driving/restraining forces. The purpose of this project was to determine an effective
intervention that would improve nurse-patient communication and increase patient satisfaction scores.
As previously indicated, the health care regulatory entities (Medicare/Medicaid) have mandated that
health care providers must meet a certain requirement for patient satisfaction as indicated by the
HCAHPS survey or risk loss of a certain percentage of reimbursement (Kutney-Lee, et al., 2009). Due to
9
the regulatory requirement, health care institutions were intensely working on reaching or exceeding this
target goal. Therefore, this project was timely. The major restraining force for this project was the
process of acquiring approval from the Research Council Committee at the project site. Nevertheless,
approval was granted.
Project need. Acquiring a statistician and financing the project was a major need, which was
eventually met. The writer spent approximately eight hundred dollars to acquire a statistician that assisted
with the project data analysis. The writer also acquired loans to meet approximately two-thirds of the
project expenses. See Appendix G.1 for a snapshot of the writer’s budget prior to project
implementation.
Project resources. Financially, resources were limited. As stated above, a loan was acquired to
meet some of the financial expenses. However, other resources such as the facility, classroom, and
projector needed to complete the project were available at no cost to the principal investigator. The
clinical facility provided the classroom and the participants did not receive additional payment for
attending the class because it was conducted during their regular work schedule. See Appendix G.2 for a
tabular form of the project approximate cost and funds.
Project sustainability. This sustainability required making educational material available, re-
enforcement of educational contents, and continuous management rounding. Champions were needed
among the staff to periodically present the education to the present and future staff. The management
needed to continue re-enforcing the use of the evaluation tool and rounding log in order to maintain
continuity of the developed skill. Furthermore, the Unit Director has the video and power point
presentation at her disposal for staff to review as needed.
Feasibility: Risks & Unintended Consequences
Risks. There was minimal risk to the participant, which related to subject information privacy in
regards to demographic data. However, a closed box was provided for participants in which to place their
completed questionnaires and demographic data to provide privacy and keep their information
anonymous. Also, participants were identified by codes with a combination of letters.
Unintended consequences. Possible consequences of ignoring this issue of communication with
nurses may result in unfavorable patient outcomes, difficulty meeting patients’ needs, unwarranted patient
care errors, multiple patient readmissions for the same problem, potential increase in the occurrence of
patient injury (such as fall), and decreased reimbursements (Kutney-Lee, et al., 2009). The Institute of
Medicine (IOM) “estimated that as many as 98,000 hospitalized Americans die each year ….not as a
result of their illness or disease, but as a result of errors in their care” (National Academy of Sciences,
2003, p.1). This estimate did not include those patients that suffered lifetime damage to their functional
ability.
10
Legally, patients expect to receive quality care. Administratively, information needed to be
available for patients to be able to make appropriate decisions about their care or any procedure that may
be necessary. Patient safety was among the top priorities when considering any policy that would have
any kind of impact on patients. Since nurses were the first contact with the patients upon admission,
nurse-patient interaction was expected to be effective and efficient. The goal of this project was to
improve staff communication skills, improve patient safety, improve quality of care, minimize/eliminate
errors, decrease readmission rate, and increase patient satisfaction. Accomplishing these elements
required collaborative efforts of all stakeholders.
Stakeholder and Project Team
Stakeholders. The stakeholders included all individuals and institutions that would benefit from
the project. These include healthcare organizations, physicians, nurses, ancillaries, patients and families,
and the population at large.
Project team. The principal investigator executed this project in collaboration with her mentor,
project chairperson, advisor, course instructors, statistician, two support persons, and two data entry
persons. The team diligently worked together in accomplishing the goal for this project.
Cost-benefit analysis
Communication skill and effective hourly rounding education was presented via video, Power
Point, and oral presentations to the staff at a Medical Unit in a classroom setting. The education was
provided during working hours, allowing for extra or overtime hours to be avoided. There was no direct
patient involvement, eliminating the issue of patient liability in the intervention phase. Other related
benefits were to maximize participants’ ability to meet patients’ expectations and exhibit caring from the
heart. It was also anticipated that studying this issue could enhance staff job satisfaction, improve survey
scores, and avoid loss of reimbursement for Medicare/Medicaid patients. Table 3 depicted the
approximate project cost to the principal investigator, the estimated indirect cost to the hospital, and
benefit analysis. Table 4 itemized the project cost and sources of funds.
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Table 3: Project Cost-Benefit Analysis
Project Cost-Benefit Analysis Costs Approximate cost to the Principal Investigator: $2,818 (See table 4 for itemized cost) Estimated indirect cost to the Hospital:
RNs (n=30 x 45)…………..$1,350 PCAs (n=15x15) …………….$225 US (n=5x15) ……………........$ 75 Classroom & Projector...…….$250 Total indirect cost …………$1,900
Benefits to the Institution Improved staff communication skill Improved patient satisfaction. Full reimbursement from the
Medicare/Medicaid and other third-party payers. Benefits to patient
Increased patient satisfaction Receive quality care Prevention of fall and injury
Benefits to the staff
Improved communication skill Job satisfaction
Avoidance of Cost Institutional Cost
Possibility of not being able to meet the required patient satisfaction score as indicated in the HCAHPS survey.
Risk the loss of a percentage of reimbursement from Medicare/Medicaid
Inadequate communication skill on the part of the staff
Patient Cost
Possible readmission due to poor discharge instruction
Dissatisfaction of care Potential risk to fall and injury
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Table 4: Costs & Funds
Principal Investigator’s Costs & Funds Items ($) Cost ($) Funds ($)
Funds Cash Loan Total Funds
1,000 2,500
3,500 Expenses Stationary: Binders…………………………………….. Printing papers …………………………… Manila Folders …………………………… Pencils, Sticker notes …………………….. Printer cartridge ………………………….. Photocopy ………………………………...
Parking at clinical practice site…………… Incentives for staff at Clinical practice sit (Pre-Intervention, Intervention phase, & Post-Intervention)………………………
Statistician………………………………… Transportation & gas………………………
98 60 5
10 500 40
310
215 800 780
Total Available Fund 3,500 Total cost 2,818
Net Balance 682 Total Project Cost (Principal Investigator’s cost (2,818) + Indirect cost to the Hospital
(1,900) = $4,718
Although it was difficult to assign a quantitative figure on the benefits that could be derived from
this project, it was obvious that any loss of reimbursement from the Medicare/Medicaid or third-party
payer per patient could be a substantial amount considering the cost of caring for each patient during
hospitalization. Additionally, with improvement in quality of care the hospital reputation would be
positively known within the community and beyond.
Mission, Vision, and Goals
Mission. The project mission was to develop and implement strategies that would improve
patient satisfaction as related to communication with nurses. This could be accomplished by optimizing
communication between nurses, patients, and the healthcare providers as a whole. Providing education
and guidance for the staff would enable them to acquire knowledge of effective and efficient inter-
professional interaction as well as staff-client relationships.
Vision. The vision was to provide quality services by working diligently with healthcare
providers to achieve their potential in patient care, to serve and care for their clients with autonomy,
respect, and dignity.
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Goals. The goal for this project was to improve staff communication skill, nurse-patient
interaction, increase patient satisfaction and achieve target scores as indicated by Hospital Consumer
Assessment of Healthcare Provider and System (HCAHPS) survey target scores at the threshold (77.4%)
or on target (78.4%).
Process and Outcome Objectives
Process objectives. The project was conducted for a period of two months. The objective was to
develop and implement strategies that would improve staff communication knowledge and skills, and
increase patient satisfaction as related to communication with nurses to achieve a target score between
77.4% and 78.4% as indicated by the HCAHPS survey. During the pre-intervention phase, which lasted
three weeks, staff level of knowledge was assessed via communication tool and hourly rounding log.
Staff communication skills were assessed via communication tool. And patient satisfaction scores were
obtained from HCAHPS survey scores in the Communication with Nurses domain.
In the intervention phase, which covered a period of two weeks, staff were educated utilizing
video (Heart-Head-Heart sandwich concept, Leebov, 2011), Power Point and oral presentation, and the
concept of 4Ps (Woodward, 2009; Ford, 2010). AIDET concept was also incorporated in the education
(Acknowledge, Introduction, Duration, Explain, Thanks) (Studer Group, 2011). The intervention phase
would be elaborate further in this paper.
The post-intervention phase was conducted for three weeks. During this phase, assessment of
staff level of knowledge was repeated via communication tool and hourly rounding log. Repeated
assessment of staff communication skills via communication tool and a most recent patient satisfaction
scores from HCAHPS survey scores in Communication with Nurses domain were accomplished. Table 5
summarized the project process objectives.
Table 5. Process Objectives
Pre-Intervention Evaluation Intervention Post-Intervention Evaluation • Assessed staff level of
knowledge • Assessed staff communication
skills • Obtained patient satisfaction
scores from HCAHPS survey scores in Communication with Nurses domain
Staff Education via: • Video (Leebov, 2011)
Power Point, & Oral Presentation
• Concept of 4Ps [Pain, Position, Potty, Placement] (Woodward, 2009, & Ford, 2010)
• AIDET concepts (Studer Group, 2011)
• Repeated assessment of staff level of knowledge
• Repeated assessment of staff communication skills
• Obtained most recent patient satisfaction scores from HCAHPS survey scores in Communication with Nurses domain.
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Outcome Objective
Hypothesized outcome objective included increased patient satisfaction as indicated by HCAHPS
survey scores at threshold (77.4%) or target (78.4%).
Procedure: Patient satisfaction was measured by HCAHPS survey. The specific questions were:
Nurses always treated you with courtesy and respect; Nurses always listened carefully to you; Nurses
always explained things in a way you could understand. The possible response was on a four point likert
scale: Never, Sometimes, Usually, and Always. The HCAHPS survey was administered by the hospital
on a continuous basis to the patients after discharge. The proportion of always satisfied patients in the
nurses’ domain on communication pre-intervention was 68.5% in the study unit. The goal was to increase
this rate to 78.4%.
Study Power: Because the duration of study was two months, and the medical unit received an
approximate number of 25 patients’ surveys returned per month, the sample size of 50 patients’ survey
was underpowered to detect the difference of about 1.0% (difference between 77.4% and 78.4%). To
have adequate power (80%) that would demonstrate statistical significance. The unit would need an
estimated 3000 patient’s survey pre- and post-intervention in order to demonstrate statistical significance.
Logic Model
The problem attempted to resolve through this project was the need to increase patient
satisfaction score to a threshold or target score (77.4% to 78.4%). The input include nurses, patient care
assistants, unit secretaries, education, Power Point and oral presentation, video, tools, resources,
incentives, hourly rounding, and management rounding. Activities involved development of tools and
implementation of evidence-based intervention with purposeful hourly rounding, education sessions for
staff and data collection, provision of visual aids such as video and Power Point presentation, and pre-
and post-intervention questionnaires. Expected output was improved staff knowledge of effective
communication and hourly rounding. Anticipated outcome was increased patient satisfaction scores at the
threshold (77.4%) or target (78.4%). The projected impact was improved communication skill, increased
patient satisfaction, and full reimbursement for the hospital. Just like any situation, a potential constraint
may impact the project or attempt to disturb the process. Such constraints included staff work schedule,
staff resistance to change, Institution Research Council Committee and IRB approval process, resources,
and funds. (Zaccagnini & White, 2011). For visual illustration of the Logic Model see Appendix C.
Population/sampling parameter. The convenience sample for the project include Registered
Nurses (RN, n=30), Patient Care Assistants (PCA, n=15), and Unit Secretaries (US, n=5), working in a
twenty-nine bed Medical Unit, in an acute care hospital in the Houston Medical Center. Total available
population N=50.
15
Setting. Education on communication skills was conducted in a classroom setting to the staff in a
Medical Unit in an acute hospital located in Houston Medical Center, Texas.
Design. In this study, a pre- and post-intervention survey was utilized to assess the impact of the
intervention (video, Power Point, oral presentation) on nurses’ level of communication skill. Patients’
level of satisfaction to nurses’ communication skills was assessed. The data for this last aim was
routinely collected by the hospital. Based on the HCAHPS survey, the pre-intervention score for the
Medical Unit under the communication with Nurses’ domain was 68.5%. After completion of the
intervention, which included educating the nurses on optimal communication, the hospital again collected
the satisfaction data from the patients.
Methodology
Pre-intervention phase. A pre-intervention baseline data was collected from HCAHPS scores,
which was 68.5%. Tools for collecting other data related to the intervention were communication tool
and hourly rounding log (See Appendix E.1 and E.2 respectively). Duration for this phase was three
weeks.
Intervention phase. Education was presented via video, Power Point, and oral presentations to
the staff (RNs, PCAs, and USs). Staff completed a pre-intervention questionnaire prior to the beginning
of the presentation to determine baseline knowledge. Staff demographic data was collected. A post-
intervention questionnaire was completed by each participant immediately after the education session.
The pre-intervention and post-intervention questionnaire completed by the participants were compared to
identify subjects’ understanding of the intervention and perceived barriers to a successful completion of
hourly rounding. Pre- and Post-intervention questionnaire can be found in Appendix E.3.
Didactic contents of the education include purposeful hourly rounding with attention to the 4Ps
(Woodward, 2009, Ford, 2010), AIDET concepts - Acknowledge, Introduce, Duration, Explanation,
Thanks (Studer Group, 2011), and video presentation of the Heart-Head-Heart sandwich concept
(Leebov, 2011). The video presentation illustrated how to appropriately respond to patients’ needs
(Leebov). The Power Point presentation focused on how to properly perform an effective hourly
rounding; re-enforcing the utilization of the 4Ps and AIDET concepts.
4Ps entailed the assessment of pain, position, potty (toileting), and placement (place call lights
and other items close to the patient, maintain eye contact); this model has been piloted and demonstrated
to have increased patient satisfaction (Woodard 2009, Ford, 2010). AIDET is an acronym created by the
Studer Group (2011) as a model for staff to address nurse-patient communication and relationship –
“Acknowledge the patient by name”… “Introduce yourself” … “Duration - give accurate time
expectation for tests” … “Explain step by step what will happen” … [and] … “Thank the patient for
choosing your hospital” (Studer Group, 2011, para. 1-5). The Heart-Head-Heart sandwich concept video
16
focused on developing caring attitude (Leebov, 2011). The presenter in this video gave examples of how
to respond to patient and their family’s concerns in a compassionate manner. These concepts were
closely related to Jean Watson’s “Theory of Human Caring” (Tomey & Alligood, 2006). Interventions
were conducted at variable hours, one hour per education session, four days per week for two weeks.
Post-intervention phase: During this phase, data were collected for comparison, which included
HCAHPS survey scores, communication tool (Appendix E.1), and hourly rounding log (Appendix E.2).
The post-intervention phase was conducted for three weeks.
Measurement
The measurement for the intervention, comparison, and the outcome was based on the pre- and
post-intervention HCAHPS survey scores to identify any significant changes in patient satisfaction. For
the intervention, the focus was whether the staff knowledge and communication skill improved. The pre
and post-intervention HCAHPS scores were compared for changes [increase or decrease in patient
satisfaction]. The projected outcome was increased patient satisfaction score between 77.4% and 78.4%.
Protection of Human Rights Procedure
The principal investigator completed a series of Collaborative Institutional Training Initiative
(CITI) courses prior to the implementation of the project. The training materials encompasses “human
research curriculum” (CITI Program, 2011, p.1). See completion reports in Appendices I.1 and I.2.
Regis University IRB and the Research Council Committee for the hospital approvals were obtained (See
Appendix H and J respectively). Additionally, code was assigned to participants for privacy and
anonymity. No informed consent was required for this project, because it focused on performance
improvement and was conducted with the Medical Unit staff only. There were no patients’ records
involved in the project. Subject participants’ questionnaires were treated anonymously. A closed box
was provided for participants to place completed questionnaires in order to maintain privacy of their
demographic data.
Instrumentation Reliability/Validity and Intended Statistics
Reliability and validity. The hospital patient survey scores utilized in this study were based on
the HCHAPS survey, which was a standardized questionnaire prepared and validated by AHRQ in
collaboration with the CMS (CMS, 2005; HCAHPS Fact Sheet, 2010). It was “formally endorsed by the
National Quality Forum (NQF)” in 2005 (CMS; HCAHPS). The CMS required hospitals to obtain and
submit a minimum of 300 HCAHPS survey scores per year. A minimum of 300 “completed surveys
over four quarters are necessary to ensure adequate statistical power to compare hospitals to one
another and to national benchmarks;” also, a minimum of 300 “completed surveys are required to
ensure an 80% chance that two hospitals that truly differ by 12% are reported as statistically
17
different” (Mode and Patient-Mix Adjustment of the CAHPS Hospital Survey (HCAHPS), 2008, p.
12).
Intended statistics. Quantitative descriptive statistics were provided for all outcomes, which
include the mean, frequency, percentage, standard deviation, and analysis of variance. All analysis was
performed in Statistical Analysis System (SAS). Estimated statistical power was 0.08, and sample
parameter was N=50. A p less than 0.05 was considered statistically significant.
Data Collection and Treatment Procedure/Protocol
Pre-intervention phase. Baseline scores for HCAHPS survey under the Communication with
Nurses domain was collected. Staff communication knowledge and skills was evaluated via
communication tool (rounding checklist) completed by the director/manager/principal investigator during
daily rounds (see Appendix E.1). Consistency was also evaluated via hourly rounding log (see Appendix.
E.2). This phase was conducted for a period of three weeks.
Intervention phase. Education sessions were conducted in a classroom setting at variable time;
each session lasted one hour, and was conducted four times a week for a period of two weeks (see
education calendar in Appendix E.5). As the participants were welcomed into the classroom, they were
given a copy of the pre-intervention questionnaire (Appendix E.3) and demographic survey (Appendix
E.4) to be completed prior to the beginning of the presentation. In order to determine the number of
attendees and how many of them completed the questionnaires, each attendee was assigned a code;
questionnaire and demographic forms were placed in envelopes prior to the session and were coded to
protect participants’ identity. Participants were instructed when to complete each of the forms to ensure
data quality and confidentiality. Post-intervention questionnaire (Appendix E.3) was completed
immediately after the presentation to assess comprehension.
Procedure #1: Staff communication skills were measured by a communication tool (see
Appendix E.1). The director/manager/principal investigator gathered information on the staff to assess
communication skill before the intervention utilizing the communication tool (Appendix E.1). The
director/manager/principal investigator again gathered information to determine what proportions of the
staff have adequate communication skill after the interventions. Adequate communication was measured
as a bivariate variable of yes/no/not applicable.
Study power: A sample size of 31(N = 31) pairs achieves 80% power to detect an odds ratio of
4.000 using a two-sided McNemar test with a significance level of 0.05. The odds ratio was equivalent to
a difference between two paired proportions of 0.3.
Procedure #2: Procedure #2 focused on staff knowledge. The study goal was to increase the
staff knowledge about effective communication. This was assessed through the pre- and post-intervention
questionnaire (see Appendix E.3) that was completed before and after the interventions, which was
18
conducted by the principal investigator. Knowledge was assessed by staff response to a series of
questions. These questions were added to compute a score ranging from 0-100. Change in score from
pre- to post-intervention was assessed. Figure 1 shows a pictorial graph of the changes.
Figure 1: Pre- & Post-Intervention Questionnaire
Study Power: 80% was considered adequate power when N = 31, and alpha was set to 0.05 to
detect a difference of 7 points between the pre- and post-intervention time interval using a two-sided
paired t-test.
Procedure #3: Measuring the extent of staff responses to the hourly rounding log (see Appendix
E.2) and whether or not they are following all the procedures was attempted. The log was expected to be
completed on an hourly basis by the Registered Nurses (RNs) and the Patient Care Assistance (PCAs)
during a twenty-four hour shift. The total possible points obtained by each RN or PCA were expected to
be 48 with a minimum of 0 points. The intended statistic was to assess a change in hourly log score by
paired T-test. This hourly log was expected to be completed by all the RNs and PCAs before and after
the intervention.
However, procedure #3 could not be analyzed statistically due to the fact that each RN and PCA
initials could not be differentiated. Therefore, the number of times the RNs and PCAs initialed the logs
were compared. That is, how many RNs initial the log within twenty-four hours as compared with how
many PCAs initial the log within twenty-four hours. The outcome only indicates RNs versus PCAs
compliance. Additionally, the log was not fully completed as directed; there were missing initials. Figure
2 depicted the hourly rounding log means per day.
19
Figure 2: Outcome #4 – Hourly rounding log means per day
Post-intervention phase. Post-intervention HCAHPS survey score was obtained. Staff
communication knowledge and skills was again evaluated via communication tool (rounding checklist)
completed by the director/manger/principal investigator during daily rounds (Appendix E.1). Staff
consistency and compliance was evaluated via hourly rounding log (Appendix E.2). This phase was also
conducted for a period of three weeks. Figure three depicted a snapshot of data collection and treatment
procedure/protocol.
20
Figure 3. Data Collection and Treatment Procedure/Protocol
Project Findings and Results
Project Findings
A total of 42 health care providers took part in this intervention. Because of missing responses
only 31 participants completed the questionnaires and demographic survey accordingly and were included
in the study results. The majority of subjects who took part in the intervention were females (93%), over
40 years old (60%) who were RN (69%), with BSN degree (39%), and over 15 years in practice (38%).
Table 6 depicted a detailed demographic data analysis. Questionnaires and survey with missing responses
were excluded in the data analysis.
Pre-intervention Phase (3 weeks)
•Baseline data collection:•Pre-intervention HCAHPS survey scores
•Evaluate communication skill (Communication Tool)
•Evaluate consistency & compliance (Hourly rounding log)
Intervention Phase(2 weeks)
•Education session: Variable time, 1hour/session, 4times/week, for 2 weeks
•Pre & Post –intervention questionnaire
•Demographic data•Assigned code to participants to protect identity
•Questionnaires & Demographic data were enveloped for privacy
Post-intervention Phase(3 weeks)
•Post-intervention HCAHPS survey score
•Evaluate communication skill changes (Communication Tool)
•Evaluate consitency & compliance (Hourly rounding log)
21
Table 6: Demographic Data Analysis (See Appendix E.4)
Analysis of intervention. Change in occurrence of various rounding checklist (see Appendix
E.1) from before to after the intervention was made via McNemar test. The extent of change in the
overall score from before to after the intervention was made via paired t-test. Furthermore, groups of
interest were compared for the change in overall score by analysis of variance (ANOVA). A p less than
0.05 was considered statistically significant.
The change in the occurrence of rounding checklists (Appendix E.1) from before to after the
intervention was examined. In this analysis only those who provided answers to both before and after the
intervention checklist were included. Thus this analysis presents data on 31 study participants. This data
was presented in Table 7, and it indicated that occurrence of most rounding checklists did in fact
increased as a result of the intervention. As compared to before the intervention, significant gains were
made after the intervention in the area of introducing oneself, specifically managing up one’s skill (65%
Subject Characters (Demographic Data)
Frequency Percent Gender Male 2 7% Female 27 93% Age 18-30 yrs. 5 18% 31-40 yrs. 7 25% 41-50 8 29% >50 8 29% Job RN 20 69% PCA 9 31% US 3 60% Years in Practice 0-5 9 31% 6-10 4 14% 11-15 5 17% >15 11 38% Education HS 7 25% Associates 8 29% BSN 11 39% MSN 2 7%
22
before vs. 90% after, p = 0.01), and for updating the whiteboard (81% before vs. 97% after, p = 0.059).
Also, as compared to before the intervention, nurses were slightly more likely to thank the patient for
choosing the hospital for their care (16% before vs. 32% after, p = 0.095) and significantly more inclined
to communicate with patients (55% before vs. 90% after, p = 0.0002) after the intervention. Specifically,
in addressing the 4Ps the intervention was related to significant improvement in asking the patient about
their pain (74% before vs. 100% after, p < 0.01), asking the patient to use the potty (30% before vs. 74%
after, p < 0.05), and moving items within reach and offering PO (eating or drinking by mouth) (83%
before vs. 100% after, p < 0.05). A small decrease in smiling when addressing the patient was seen after
the intervention (p = 0.047), although the actual rate of event was quite high both before (97%) and after
the intervention (84%). (see table 7).
The overall subject score increased by nearly 15 points from before to after intervention (mean
74.1 to 89.1), a gain that was statistically significant at p less than 0.001 (see table 7). Furthermore, in
order to assess if the change in the total score varied as a result of any characteristic, change in total
evaluation score by staff age, gender, job status, and number of years in practice and years in the Medical
Unit was examined. This data was presented in Table 8. Overall, change in score did not vary by any of
the characteristics studied.
23
Table 7. Changes in Communication Skill
See Appendix E.1: Communication Tool
Acknowledge
Before N=31 After N=31
1 30(97%) 31(100%)
2 29(94%) 31(100%)
3 30(97%) 26(84%) **
4 20(65%) 28(90%) *
5 25(81%) 30(97%) !
Duration
1 8(26%) 13(42%)
2 9(29%) 10(32%)
3 3(10%) 7(23%)
4 17(55%) 28(90%) **
Explain
1 31(100%) 30(97%)
2 6(20%) 8(26%)
The 4Ps
1 23(74%) 31(100%)
2 22(71%) 24(77%)
3 8(26%) 20(65%) *
4 25(81%) 31(100%) *
Closing 1 5(16%) 10(32%) !
2 15(48%) 29(94%) **
3 26(84%) 27(87%)
Total Score (Mean, SD)
74.1 89.1**
LEGEND For Tables 6, 7, & 8
NS = Not Statistically Significant
** = p < 0.001
* = p < 0.05
! = p < 0.1
24
Table 8. Changes by years of practice, age, gender, job, and years in the Medical Unit
Years in Practice
1(0-5) 2(6-10) 3(11-15) 4(>15) N=9 N=4 N=5 N=11 Change by years in practice (Mean) 15.3 13.8 14.8 15.2 (NS)
Age 1(18-30) 2(31-40) 3(41-50) 4(>50) N=5 N=7 N=8 N=8 Change by years in practice (Mean) 15 15 14.3 12.9 (NS)
Gender Male Female N=2 N=27 Change by years in practice (Mean) 15 14.9 NS
Job 1(RN) 2(PCA) N=20 N=9 Change by years in practice (Mean) 16.1 12.3 (NS)
Years in the Medical Unit 1(0-5) 2(6-10) 3(11-15) 4(>15) N=15 N=5 N=6 N=3 Change by years in practice (Mean) 13.3 15.4 20.3 11.7 (NS) NS = Not Statistically Significant (See Appendix E.4: Demographic data questionnaire)
Project outcomes results. The total number of patients who completed the HCAHPS survey
during the course of this project was fifty-nine (n = 59). Pre- and Post-intervention HCAHPS survey
scores were compared. Pre-intervention score for Communication with Nurses domain was 68.5% and
Post-intervention score was 93%. This positive result was evidence that there was an improvement in the
staff communication knowledge and skills, and a substantial increase in patient satisfaction. The
increased patient satisfaction revealed that education could be effective in building nurses’
communication skill. Figure 4 display a graphic snapshot of the increase in HCAHPS scores.
25
Figure 4
Limitations, Recommendations, Implications
Limitations
Limitations for this project include small sample and missing data. In addition, the project was
limited to one patient unit with limited time (project was conducted for a period of two months). Out of
forty- two staff participants, only thirty-one completed all the required information. Furthermore, the
hourly rounding log (Appendix E.2) could not be statistically analyzed. Additionally, a few members of
the staff could not attend the educational session due to staff shortage. Based on the principal
investigator’s observations, some of the patients may not be able to complete the HCAHPS survey due to
their physical conditions, this could potentially reduce the number of surveys returned.
Recommendations
For nursing. Sustainability of the improvement in the staff communication skill and patient
satisfaction requires persistency in the application of the educational contents, specifically hourly
rounding with the integration of AIDET script (Acknowledge, Introduction, Duration, Explain, Thanks),
and management rounding. A periodic presentation of the education is recommended, which could
decrease staff knowledge relapse. Newly hired employees who have not been exposed to such
presentations could also benefit from periodic presentation of this educational intervention.
Additionally, based on principal investigator’s observation regarding shortage of staff during the project
implementation period, availability of adequate staff is an essential ingredient for sustained improvement
0
20
40
60
80
100
Pre & Post Interventions
Pre-Intervention & Post-Intervention HCAHPS Survey Scores
Pre-Intervention
Post-Intervention
26
in staff communication skill and patient satisfaction. In essence, it may be necessary to consider
favorable patient-to-nurse ratio, which will enable nurses to spend more time with their patients.
For nursing theory. Pilot and integrate Jean Watson’s Theory of Human Caring into nursing
practice, particularly bedside nursing. This could help to expose some of the essential elements of the
theory to those areas of nursing that are presently lacking the effective application of caring behavior.
Caring is one of the fundamental pillars of nursing (Chitty, 2005). When caring behavior is not portrayed
in patient care, it may generate negative perception in healthcare delivery. For research. A repeat of this project with larger samples is recommended in order to truly
allow for generalization of the findings and results. This project would also benefit from increasing study
duration and conducting a pilot study in an alternative hospital setting. Such locations include a Skilled
Nursing Facility (SNF) and Long Term Acute Care (LTAC) facility to establish reliability/validity and
generalization.
For Advance Practice/Leadership education. Findings from this project could be further
evaluated through literature review and critique. The works in this paper could be utilized in developing
some of the elements of education in higher institutions. Moreover, the project may be repeated by
students in advanced learning institutions to further validate the effectiveness of the intervention.
For health policy. The following may need to be considered for better improvement in
HCAHPS survey results and healthcare delivery: Periodic evaluation of the survey contents; evaluation
of the hospital systems on the application of HCAHPS survey; review of hospitals’ nursing staffing and
nurse-to-patient ratio in order to determine the root cause of patients’ dissatisfaction.
Implications For nursing. The implication for nursing was improved communication skill by virtue of
HCAHPS scores. Other implications included potential decrease in call light use, potential decrease in
falls, and potentially prevention of injury.
For hospital. With effective communication skills, staff will be able to provide effective nurse-
patient interaction that can potentially lead to increased patient satisfaction, prevent loss of
reimbursement, and potentially decrease patient liability. Additionally, the hospital could experience
increase in referrals, and a more virtuous status in the community.
For patient. The implication to the patient includes quality care, potential decrease in anxiety,
and potential improvement in safety. Improved nurse-patient communication would enable patients to
develop trust in nursing care, which potentially may lead to speedy recovery. In essence, improved staff
communication skills would eventually increase patient satisfaction.
27
Conclusion
Quality of care is the precursor for patient satisfaction (Wagner & Bear, 2008). Patient
satisfaction is a pivotal issue in the healthcare system today. Health care organizations must meet certain
requirements in HCAHPS survey to receive full reimbursement for Medicare/Medicaid patients (Wagner
& Bear). Therefore, educating staff regarding effective communication and hourly rounding is essential.
Further, consideration may be needed in the area of favorable patient-to-nurse ratio. The issue of patient
satisfaction may be attributed to ineffective communication with nurses, ineffective nurse-patient
interaction, and low HCAHPS survey scores. In essence, implementation of staff education regarding
effective communication and hourly rounding, with close consideration of patient-to-nurse ratio, will
enable nurses to spend more time with their patients, complete tasks in a timely fashion, and minimize or
eliminate unwarranted errors or patient injury.
Based on literature review, it appears improved nurses’ interaction with patients could lead to
increased patient satisfaction scores in HCAHPS survey (Kutney-Lee, et al, 2009). In order to achieve
this goal of increased patient satisfaction scores, it was imperative that a behavioral change was
established. Improving how patient care was conducted may be considered as one of the most important
solutions to patient satisfaction. To this effect, it was obvious that nurses need to spend more time with
their patients in order to develop a positive relationship and be able to utilize their communications skills
effectively.
This project displayed positive outcomes of improved staff communication skills, improved
nurse-patient interaction, and increased patient satisfaction scores; therefore, foreseeable long-term
impact includes improvement in patient trust, as well as employee, physician, and patient satisfaction.
Based on the systematic literatures reviewed (see Appendix B) and other materials, education has been
found to be one of the most effective tools in augmenting staff communication skills. Literatures
reviewed for this project also indicated that Hourly rounding has been piloted and also found to be
effective in reducing falls, improving safety, and increasing patient satisfaction. Although this project
was completed with a small sample size, it indicated a promising trend in increase of HCAHPS
communication with nurses’ scores. The project revealed that focused education could be effective in
building nurses communication skills and increasing patient satisfaction.
28
References
Abdellah F.G. & Levine F. (1957). Developing a measure of patient and personnel satisfaction with
nursing care. Nursing Research, 5, 100-108.
Bass, B.M. & Avolio, B.J. (1993). Transformational leadership: A response to critiques. In C.E.
Johnson (Ed.). Normative leadership theories. Meeting the Ethical
Challenges of Leadership (2nd ed., pp.159-160). Thousand Oak, CA: Sage Publication.
Brady, K.T. (2006). Bureau of Labor Statistics shows greater needs for nurses. Retrieved from
http://news-business.vlex.com/vid/bureau-labor-statistics-greater-nurses-68767650
Center for Medicare & Medicaid Services (2005). Hospital CAHPS (HCAHPS) Fact Sheet: Center for
Medicare & Medicaid Services and Agency for Healthcare Research and Quality. Retrieved
from
http://www.cms.gov/HospitalQualityInits/downloads/HospitalHCAHPSFactSheet200512.pdf
Center for Medicare & Medicaid Services (2012) HCAHPS Quality Assurance Guideline V7.0. Retrieved
from http://www.hcahpsonline.org/qaguidelines.aspx
Chitty, K.K. (2005). Defining nursing: Harder than it seems. In T. Wilhelm, & J. Downing (Eds).
Professional Nursing Concepts & Challenges (4th Ed.). St Louis, MI: Elsevier Sanders.
Clark, L. (2008). Clinical leadership: Values, beliefs and vision. Nursing Management,
15(7), 30-35.
Collaborative Institutional Training Initiative [CITI] (2011). Human research curriculum. Retrieved
from https://www.citiprogram.org/aboutus.asp
Cutler, D.M. (2008). The American healthcare system. Medical Solution. Retrieved
from http://www.economic.harvard.edu/faculty/cutle
Ford, B.M. (2010). Hourly rounding: A strategy to improve patient satisfaction scores.
MEDSURG Nursing, 19, p.188-191.
Fortenberry, Jr., J.L. (2010). The SWOT analysis. Health Care Marketing: Tools and Techniques
29
(3rd ed.). Sudbury, MA: Jones and Bartlett.
Garson, A. (2000), The US healthcare system 2010: Problems, principles, and potential
solution. Journal of the American Heart Association. Retrieved from
http://circ.ahajournals.org/content/101/16/2015
Guralnik, D.B. (1986). Webster’s new world dictionary of the American language (2nd ed.).
Eaglewood Cliffs, NJ: Prentice Hall.
HCAHPS Fact Sheet (2010). HCAHPS development, testing and endorsement. Retrieved
from http://www.hcahpsonline.rg/facts.aspx
Henderson, A., Eps, M. A. V., Pearson, K., James, C., Henderson, P. & Osborne Y. (2007).
‘Caring for’ behaviors that indicate to patient s that nurses ‘care about’ them. Journal of
Advanced Nursing, 60, 146-153.
Hinshaw, A.S. & Atwood, J.R. (1981) (as cited in Wagner & Bear, 2008). A patient satisfaction
instrument: precision of replication. Nursing Research, 31, 170-175.
Houser, J., Oman, K.S. (2011). Evidence-based practice. An implementation guide for healthcare
organizations. Sudbury, MA: Jones & Bartlett.
Institutes of Medicine (2000) (as cited in National Academy of Sciences, 2004). Keeping patients safe:
Transforming the work environment of nurses. Retrieved from
http://www.nap.edu/openbook.php?record_id=10851&page=1
Irish Society for Quality & Safety in Healthcare (2003). Measurement of patient satisfaction
guidelines: Health strategy implementation project. Retrieved from
http://lenus.ie/hse/bitstream/10147/43559/1/3498.pdf
Jha, A. K., Orav, E. J., Zheng, J., & Epstein, A. M. (2008). Patients’ perception of hospital care in the
United States. The New England Journal of Medicine, 359, 18
30
Johnson, C.E. (2005). Meeting the ethical challenges of Leadership (2nd Ed.). Thousand Oaks, CA: Sage
Publication.
Kutney-Lee, A. McHugh, M. D., Sloane, D. M., Cimiotti, J. P., Flynn, L., Neff, D.F., & Aiken, L. H.
(2009). Nursing: A key to patient satisfaction. Health Affairs, 28.
Larrabee, J. H., Ostrow, C. L., Withrow, M. L., Janney, M. A., Hobbs Jr., G. R., & Burant C. (2004).
Predictors of patient satisfaction with inpatient hospital nursing care. Research in Nursing &
Health, 27, 254-268.
Leebov, W. (2011). The language of caring skill-building program. Retrieved from
http://www.quality-patient-experience.com/language-of-caring.html
Liu, J., Mok, E., Wong, T., Xue, L., & Xu, B. (2007). Evaluation of an integrated communication skills
training program for nurses in cancer care in Beijing, China. Nursing Research, 56 (3), 202-209.
Lo, C., Burman, D., Rodin, G., & Zimmermann, C. (2009). Measuring patient satisfaction in
oncology palliative care: Psychometric properties of the FAMCARE-patient scale.
Quality Life Res, 18, 747-752.
Lockwood, W. (2011). What are health care regulatory agencies? Retrieved from
http://www.ehow.com/about_5187634_health-care-regulatory-agencies_html
McBride, A.B. (2011). The growth and development of nurse leaders. New York, NY: Springer.
Mead, C.M., Bursell, A.L., & Ketelsen, L. (2006). Effect of nursing rounds on patients’ call light use,
satisfaction, and safety. American Journal of Nursing. 106(9), 58-71.
Mode and patient-mix adjustment of the CAHPS Hospital Survey (HCAHPS) (2008).
Questions and answers regarding adjustment. Retrieved from
http://www.hcahpsonline.org/modeadjustment.aspx
Mrayyan, M.T. (2006). Jordanian nurses’ job satisfactions patients’ satisfaction and quality of nursing
care. International Nursing Review 53, 224-230
31
National Academy of Sciences (2004). Keeping patients safe: Transforming the work environment of
nurses. Retrieved from http://www.nap.edu/openbook.php?record_id=10851&page=1
Pipe, T.B. (2006). Optimizing nursing care by integrating theory-driven evidence-base practice. Journal
of Nursing Care Quality 22(3), 234-238.
Riggio, R.E. (2009). Cutting-edge leadership. Psychology Today. Retrieved from
http://www.psychologytoday.com/blog/cutting-edge-leadership/200903/are-you-
transformational-leader
Risser, N.L. (1975). Development of an instrument to measure patient satisfaction with nurses and
nursing care in primary care settings. Nursing Research 2, 45-52.
Rodwin, M.A. (2010). The metamorphosis of managed care: Implications for health reform
internationally. Journal of Law, Medicine & Ethics, 38(2), 352-64.
Stephens, J.H. & Ledlow, G.R. (2010). Real healthcare reform: Focus on primary care Access.
Hospital Topics, 88(4), 98-106.
Studer Group (2011). Hardwire the five fundamentals of service. Retrieved from
http://www.studergroup.com/tools/key_wordsatkeytimes/HardwiretheFiveFundamentalso
fService.pdf
Tea, C., Ellson, M. & Feghali, F. (2008). Proactive patient rounding to increase customer
service and satisfaction on an orthopedic unit. Orthopedic Nursing, 27(4), 233-42.
The American College of Physicians (2009). Interprofessional collaboration. In M.E.
Zaccagnini & K.W. White (Eds.). The doctor of nursing practice essentials. A
new model for advanced practice nursing p.237. Sudbury, MA: Jones and Bartlett.
Tommy, A.M., & Alligood, M.R. (2006). Nursing theorists and their work. In Y. Alexopoulos, and
K. Hebberd (Eds). St. Louis, MO: Elsevier.
Torres, S. M. (2007). Rapid-cycle process reduces patient call bell use, improves patient satisfaction, and
anticipates patient’s needs. Journal of Nursing Administration, 37(11).
32
Vance, T. (2003). Caring and the professional practice of nursing. RN Journal. Retrieved from
http://www.rnjournal.com/journal_of_nursing/caring.htm
Wagner, D. & Bear, M. (2008). Patient satisfaction with nursing care: A concept analysis within a
nursing framework. Journal of Advanced Nursing. 65(3), 692-701.
Wastely, T.P. (1993). Health care in the twentieth century: A history of government interference
and protection. Retrieved from
http://finfarticles.com/p/articles/mi_m1094/is_n2_v28?ai_13834930
White, S.J., (2009). Success skills: Your professional practice vision. American Journal of Health-
System Pharmacy, 66, 1434 -1435
Woodward, J. L. (2009). Effect of rounding on patient satisfaction and patient safety on a medical-
surgical unit. The Journal for Advanced Nursing Practice, 23(4), 200-6.
Yordy, K.D. (2006). The nursing faculty shortage: A crisis for health care. Association of Academic
Health Centers (AAHC). Retrieved from
http://www.rwjf.org/files/publications/other/NursingFacultyShortage071006.pdf
Zaccagnini, M. E., & White, K. W. (2011). The doctor of nursing practice essential: A new model for
advanced practice nursing. Sudbury, MA: Jones and Bartlett.
33
Appendix A
Watson’s 10 conceptual Carative Factors
• “Humanistic-Altruistic system of value”
• Creating “Faith & Hope”
• “Sensitivity to self and others”
• Creating “helping-trust relationship”
• “Expression of positive and negative feelings”
• “Use of the scientific problem-solving method for decision-making”
• “Promotion of transpersonal teaching-learning”
• Providing “supportive, protective, and corrective mental, physical, sociocultural, and spiritual
environment”
• “Assistance with gratification of human needs”
• Allowing “existential phenomenological forces”
(Tomey & Alligood, 2006, p. 104)
34
Appendix B
Systematic Literature Review
Systematic Review Evidence Table Format [adapted with permission from Thompson, C. (2011). Sample evidence table format for a systematic review. In J. Houser & K. S. Oman (Eds.), Evidence-based practice: An implementation guide for healthcare organizations (p. 155). Sudbury, MA: Jones and Bartlett.]
1 2 3 4 5 6 7
Article Title and Journal
Patient satisfaction with nursing care: a concept analysis within a nursing framework. Journal of Advanced Nursing 65(30), 692-701
Measuring the effect of patient comfort rounds on practice environment and patient satisfaction: A pilot study. International Journal of Nursing Practice, 15: 287-293
Measuring patient satisfaction in oncology palliative care: psychometric properties of the FAMCARE-patient scale, Qual Life Res., Vol. 18, 747-752.
Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: A Comparison of Verbal vs. Visual Assessment. Journal of Health Communication, Vo. 11, 651-644.
Rapid-Cycle Process Reduces Patient Call Bell Use, Improves patient satisfaction and anticipates Patient's Needs. Journal of Nursing Administration, Vol. 37(11), November 2007.
Implementing a Caring Model to Improve Patient Satisfaction. Journal of Nursing Administration, Vol. 29 (12), 30-7.
Assessing Family Satisfaction with Care of Critically ill Patients: A Pilot Study. American Association of Critical-Care Nurses, Vol. 30(6).
Author/Year
Debra Wagner & Mary Bear (2008)
Glenn Gardner, Kaylene Woollett, Naomy Daly, & Bronwyn Richardson, (2009).
Christopher Lo, Debika Burman, Gary Rodin, & Camilla Zimmermann (2009)
Dean Schillinger, Frances Wang, Jorge Palacios, & Maytrella rodriguez, (2006)
Susan M. Torres, (2007)
Dingman, S. K., Williams, M., Fosbinder, & D., Warnick, M. (1999).
Susan M. Roberti, Joyce J. Fitzpatrick (2010)
Database and Keywords
Regis University database: CINAHL. Keywords: Concept analysis, Interaction Model of Client Health Behavior, nursing care, nursing framework, patient satisfaction.
Academic Search Premier Nursing practice, nursing practice environment, patient comfort rounds, patient satisfaction, pilot study.
Academic Search Premier. Keywords: Patient satisfaction, Palliative care; Cancer; FAMCARE; Psychometrics.
Regis University Library database. Keywords: Communication, Patient Satisfaction, Assessment,
Regis University Library database: CINAHL. Keywords: Patient Satisfaction
CINAHL. Keywords: Patient satisfaction; Caring; Nurse-Patient Relations; Hospitals; Community; Nursing Care.
CINAHL. Keywords: Patient satisfaction, Communication.
Research Design
Theoretical Framework
Quasi-experimental pilot study, non-randomized parallel group trial design.
Cross-sectional study
Qualitative design
Rapid-Cycle process, Pilot design, utilizing Model of Care (MOC).
Descriptive design Pilot study
35
Level of Evidence Level IV Level IIIC Level IIIB
Level I: Other studies were cited, although not on anticoagulant, but on other medications.
Level I: other studies as related to patient satisfaction were cited. According to the author this study was prompted by the patients' response to a standardized survey regarding "prompt response to call bell". Level IIIB
Systematic literature review. Level 1
Study Aim/Purpose
Report of a concept analysis of patient satisfaction with nursing care.
To test the effect of a 1-hourly patient comfort round intervention on patient satisfaction and on nursing perceptions of the practice environment. To test the effect of a model of practice that optimized the role of the assistant-in-nursing (AIN) in skill mix.
"Provide preliminary psychometric results concerning the use of a modified FAMCARE scale, adapted for patient use , to assess satisfaction with outpatient care in advanced stage cancer patients"
Study Aim/Purpose: Effective communication about medications. "Evaluate or Measure rate of miscommunication, and differences between verbal and visual modes of assessment. Assess concordance between patient and clinician reports of warfarin regimens."
"To identify the nature of patient requests using the call bell, determine best practice interventions to anticipate patients' needs, and improve patient satisfaction through anticipatory nursing care."
"To evaluate the effect of implementing a Caring Model on patient satisfaction."
To assess "family satisfaction with care of critically ill patients".
36
Population Studied/Sample Size/Criteria/ Power
Population: Inpatients. Sample: 44 papers published in English between 1998 and 2007. No power analysis.
Population: Patient in acute hospital and Nurses in acute hospital. Total sample: 129.
145 outpatients with advanced cancer who were participating in a phase II trial of an outpatient palliative care intervention. Criteria: Participation in a phase II trial of an outpatient palliative care intervention. Correlation with ESAS P = 0.02; association with depression p = 0.03; association with anxiety p = 0.01; association with fatigue P = 0.06; association with appetite P = 0.07.
Population study: "Ethically diverse and low socioeconomic status patients in an anticoagulation clinic." 220 patients were studied. P < 0.05.
Inpatients in 3-model of care units. No specific sample size indicated. Collection tool was design to record patients' call: time of call, nature of call, and patient request.
Staff/Patients in an acute care hospital with 48 beds. Sample: 48 staff (45 women, 3 men) and 298 patients. P = 0.05
Critically ill patients admitted in a medical surgical intensive care unit and telemetry/intermediate care unit in a community hospital. N= 31. Exclusion Criteria: Family member with language barrier, family member of nonsurvivors, family member must be 18 years old or older and must consent to participate in the study.
Methods/Study Appraisal/ Synthesis Methods
Literature review. Framework utilized: Interaction Model of Client health Behavior (IMCHB). Pilot study
Exploratory factor analysis of the patient satisfaction measure and correlation of patient satisfaction was performed.
Use of Questionnaire/interview, one-on-one, and verbal/visual aids: pictures of the different shapes and colors of warfarin/Coumadin.
Team was formed, which consist of the Unit Manager, Nurse Educator, Licensed and Unlicensed staff. The team developed a pilot design that was utilized in recording patients' calls. Ninety-nine calls were recorded within 24hours and analyzed based on time and purpose of calls.
"Eight patient satisfaction attributes were incorporated into a Caring Model. Five selected caring behaviors were created, which staff need to verbalized when introducing themselves to their patients. Education in-services were given to the staff. Pre-intervention and post-intervention evaluation was utilized to measure the outcome of the model".
Survey. Convenience sample of 31 patients' family member (one family member per patient) were asked to fill out survey and dropped in a locked box to keep them confidential.
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Primary Outcome Measures and Results
Patient satisfaction increases with enhancement of nursing quality.
Result shows no significant changes in patient satisfaction.
"Factor analysis of the satisfaction measure revealed a one-factor structure and suggested the removal of one non-loading item, producing a 16-item scale (FAMCARE-P16) with high internal reliability. Patient satisfaction was not correlated with performance status, but was inversely associated with symptom burden, particularly with depression and anxiety."
Patients were "categorized as having verbal discordance if there was no patient clinician discrepancy in the total weekly dosage of warfarin when the patient verbalized the regimen and visual concordance if there was no patient-clinician discrepancy in the total weekly dosage when the patient identified the regimen from the digitized pill menu." "Neither language nor health literacy was associated with visual discordance. Shifting from verbal to visual modes was associated with greater patient-provider concordance across all patient subgroups, but especially for those with communication barriers.
The most frequent requests were: Positioning and pain medication, less frequent calls: Intravenous machine beeping, questions regarding care, and accidental bell use. Other less frequent calls: request to turn TV or light off, reaching for tissue or drink.
"Post-intervention, the patient satisfaction attributes of Nurse Anticipating Needs and Responds to Requests significantly increased."
Study outcome indicated that family members were generally satisfied.
38
Author Conclusions/ Implications of Key Findings
There is evidence in the literature that nursing care and patient satisfaction are interwoven. Importance of improvement in nurse/patient interaction was emphasized as related to patient's perceived experience during hospitalization. Finding a way to improve patient satisfaction is a crucial for nurses to be able to have a marked impression on patients' hospital experience
Despite limited funds and other limitations, the study achieve its goal, "it confirmed that nurse-led, patient-centered and quality-of-care-oriented therapeutic interventions can have a positive effect on the nursing practice environment, and therefore potentially on patient safety and satisfaction.
"The items of the FAMCARE-P cohered into a single patient satisfaction factor, except for one item concerning satisfaction with pain relief. Recommend further research for consideration of further scale validation.
The authors concluded that clinician-patient discordance in the weekly warfarin regimen is common, but occurs less frequently when patients report their regimen using a visual aid. Language and inadequate health literacy are independently associated with verbal but not visual. The authors also emphasized that "communication barriers, such as limited English proficiency and limited health literacy, are associated with lower quality of care ad place patients at risk for poor clinical outcomes". Advert effect could be prevented when patients receive proper communication about their medication.
It was concluded that application of this study followed with appropriate/targeted intervention for a period of 12 months leads to decrease in overall patients' calls. It was also "suggested that the activity of hourly rounding combined with stepwise tasks had positive results on patient satisfaction and safety and decreased call bell use.
"Study provides evidence that nurse caring behaviors can influence patient satisfaction. For a Caring Model to be effective, it must be strategically planned and be implemented throughout the organization. Sustaining the effect of the Model require frequent reminders among staff members. Nurse caring is an important predictor of patient satisfaction."
Patients' families were satisfied with the care given to their loved ones; staff education was emphasized; developing a strategic manner of addressing patients' families concerns was also emphasized.
39
Strengths/ Limitations
Outcome support the effect of nursing care on patient satisfaction; but the sample was very small, thus hindering generalization of the outcome.
Insufficient fund and organizational issues leads to limited sample size.
Strength: Sample, possibility of been able to generalize the result; FAMCARE-P can measure patient satisfaction with palliative care inpatient or outpatient. Limitation: Research approach toward scale construction and revision, per authors' suggestion, further study is needed for a better assessment of palliative care intervention.
Strength: Implication for reducing medication-related errors. The study reveals that language barrier and health literacy could cause patient to have medication errors. The study indicates that patients' self-report regarding their medication is the best means of collecting accurate data, which could help to identify patients' adherence to their medication regimen. Limitation: "Subjects were recruited from one anticoagulation clinic, which may limit generalizability;" "method of determining regimen concordance"; Utilization of research assistants in obtaining patient reports; Sample size was too small per the authors conclusion
Strength: Piloting the study first, and applicability of the study to other Units. Including the staff in the process, Using more than one Unit for comparison.
Strength: Large Sample size; generalization of the result - Four other hospitals implemented the caring model after the study was completed; Support from other studies. Limitations: "Trending over the next two quarters following the study is necessary to validate the overall effectiveness of the model."
Limitation: Convenience sample was used, which could hinder generalization of the study.
40
Funding Source
No specific funding from any agency.
Study was funded by Royal Brisbane and Women's Hospital Foundation
Supported in part by grant from National Cancer Institute of Canada. Canadian Cancer Society and Edith Kirchmann Fellowship in Psychosocial Oncology and Palliative Care at Princess Margaret Hospital.
Research was funded with grants from the American Heart Association; Agency for Health Research and Quality; National Center for Research Resources; and the UCSF Hellman family Research Award.
There was no indication of how this study was funded in the article.
No funding source was listed in this article.
Financial disclosure was not reported
Comments
The author emphasized the importance of nursing care and its impact on patient satisfaction. If patients are satisfied with nursing care, they would be eager to refer friends and family to the hospital, they would more than likely return to the hospital for care, they would be more compliance with their treatment regimen, and eventually have a speedy recovery. Nurses need the essential skill to effectively communicate with their patient in regards to patient satisfaction.
Patient satisfaction is essentially a mandatory goal for all healthcare hospital today. The HCHAP survey has a stipulated target for each area of care that must be met for a full reimbursement starting from year 2013. Hence it is imperative that solution to this issue must be established as soon as possible, meaning patient’s perception of care needs to be met. My project is focusing into how this need could be met considering nurses-patient interaction.
The study focuses on oncology palliative care, but the result is applicable to other areas of care. Proving to patients that you care require meeting his/her expectation. If the expectation is about psychological issue, regardless of the extensiveness of the physiological issue and how much care is given in that area, the psychological issue need to be addressed for the patient to recognized that he/she has been very well cared for, particularly nursing care.
Based on the author’s conclusion, this study could not be generalized because sample and data were obtained from one clinic. Therefore, there is a bias in the outcome and result of the study. Language barrier was an issue, there may be missing information during the process of interpretation of patients' report, hence, accuracy and validity of the report is questionable. Patients would like to know more than the colors of their medications, such as what the medication is meant for and the side-effects in order to prevent grievous medication errors; improved communication with nurses could help in this area.
This article focuses on "anticipatory needs". In essence, if we anticipate that patient would need certain thing at a certain time and we meet that need before the patient calls, then we could be able to influence patient's perception in a positive manner. For example, it is obvious that a post-operative patient would probably have a lot of pain within the first 24 hours after surgery; an hourly round would enable the nurse to determine when the patient is in pain or when to give the next pain medication. Therefore minimizing or eliminating patient's pain would positively affect patient's perception of his/her care, thereby increase patient satisfaction.
Establishing good caring that could lead to patient satisfaction is vitally needed today more than ever before. Elements in this study could be very resourceful for my project. I could identify multiple ideas that are applicable to what is already in place at my clinical practice site. I would probably add some of the interventions to my PICO. There is no doubt that this model would be effective in any health care services if properly implemented.
Although this study focused on families of patients in critical care unit, it could be generalized to regular units as well because many of these patients are being transferred to the medical units prior to discharge. Therefore the trend of meeting the families concern must be continued when patients are transferred to regular units. My project will benefit from the contents of this article.
41
Article Title and Journal
Effect of Nursing Rounds on patients' call light use, satisfaction, and safety: scheduling regular nursing rounds to deal with patients' more mundane and common problems can return the call light to its rightful status as a lifeline. American Journal of Nursing Vol. 106(9), 58-71
The effect of emergency department staff rounding on patient safety and satisfaction. Journal of Emergency Medicine, Vol. 38(5), pp.666-674.
Initiating a Patient Service Partner Program. Nursing Management, 1996, Vol. 27(10), 46, 48-50
Implementing Ask Me 3 To Improve African American Patient Satisfaction and Perceptions of Physician Cultural Competency. Journal of Cultural Diversity, V. 17(2), p62-67.
Utilizing an outcomes approach of improve pain management by nurses: a pilot study. The Journal of Advanced Nursing Practice, Vol.12 (1): 28-36
Changing unit culture: an interdisciplinary commitment to improve pain outcomes. Journal for Healthcare Quality, Vol. (27 (2). 12-9.
Patient satisfaction and pain management: an educational approach. Journal of Nursing Care Quality, Vol. 19(4), 322-7.
Author/Year
Meade, C. M., Bursell, A. L., & Ketelesen, L. (2006).
Christine M. Meade, Julie Kennedy, and Jay Kaplan, (2008).
Patricia Gersch, (1996).
Georgia Michalopoulou, Pamela Falzaranol, Cynthia Arfken, & David Rosenberg (2010).
Barmason, S., Merboth, M., Pozehl, B., Tietjen, M.J., (1998)
Chung, H., Nguyen, P.H. (2005)
Innis, J., Bikaunieks, N., Petryshen, P., Zellermeyer, V., Ciccarelli, L. (2004)
Database and Keywords
Ovid. Keywords: Call light, Rounds, Patient safety, Patient satisfaction, Learning, Patient care management.
Academic Search Premier. Keywords: Patient safety; left without being seen, leaving against medical advice; patient satisfaction; ED staff interruptions.
CINAHL. Keywords: Patient satisfaction, rising cost, patient service partner.
Academic Search Premier. Keywords: Patient satisfaction; African American - Medical care; Cultural competence; Physician & patient; Patient-entered care.
Ovid. Keywords: Pain, Treatment outcomes, nursing staff, hospital, staff development, nursing interventions.
Ovid. Keywords: Change Theory, Organizational Change, Pain management, Quality Improvement.
CINAHL. Keywords: Education, pain, patent satisfaction.
42
Research Design
Quasi-experimental design.
quasi-experimental design
It is not clear what design was utilized in this article, but the design appears to be a single experimental study.
Control study/Qualitative
Pilot study/Qualitative
Descriptive design
Qualitative design
Level of Evidence Level IIIA Level II
It is not very clear which level this study really belongs. However, Level IIIC seems to be the closest level based on the single experimental study. Level IIIB Level IV Level IV Level IIIB
Study Aim/Purpose
"To determine the frequency of and reasons for patients' call light use, the effects of one-hour and two hour nursing rounds on patients' use of the call light, and the effects of such rounding on patient satisfaction, as well as patient safety as measured by the rate of patient falls."
To test the effectiveness of three different rounding techniques and to determine the most effective rounding technique of the tree types tested.
The study focused on patient satisfaction
"To improve African American patient satisfaction and perceptions of physician cultural competency."
"To measure the effectiveness of a structured intervention to improve pain management for patients."
"To individualize pain management through daily rounds and improvements in nursing assessment."
"To examine the impact of pain education on patient satisfaction with pain management. To increase patient satisfaction as related to pain management; to increase nurses' knowledge of pain assessment and management, and nursing documentation of patients' pain."
43
Population Studied/Sample Size/Criteria/ Power
Population: Nursing units selected in 14 hospitals. Sample: 22hospitals from 14 states, and 46 units. Criteria: Each participating hospital must meet the following criteria: Have Per Diem staff from outside agency is medical units, strong nurse manager, at least one hospital unit in the control group and one in the experimental group. Power: For one-hour rounding - t = 3.074, P = 0.01; Two-hour rounding - not significant, and Control group - not significant.
Population: Emergency departments. Sample: 28 Emergency departments. Criteria: Fast track section of the ED were excluded; inform consent were provided by each ED manager; standardized visual training was given to each department; a written test is required after staff watch the video; ED leaders must round regularly with staff. Power: Patient LWBS (Leaving Without Being Seen)-P = 0.05
Surgical Patients in two Patient Care Unit, and a Critical Care Unit. Sample: 28 patients. No specific criteria included in this study. P < 0.05
Adult African American; sample: 64; "low income and low education attainment."
Population: Patients/nurses; Sample: 47 patients and 125 nurses; P < 0.001.
Population: Staff at Medical unit at The Methodist Hospital System. No specific figure of sample indicated in the article.
Population: Inpatient, and nurses in the internal medicine unit. Sample: 50 inpatients, 93 nurses. Criteria: Excluded patients - post-operative patients, patients in high intensive critical care step-up unit, patient with dementia, patients admitted against their will, palliative care patients. Excluded nurses - Those who were on maternity leave or vacation. p<.05
44
Methods/Study Appraisal/ Synthesis Methods
Method: Nationwide six-week study, utilizing quasi-experimental nonequivalent groups design, investigator-controlled. Study Appraisal: No assurance as to whether all the staff complied with the requirement for rounding. Survey calculation was based on vendors' data, possibility of staff modifying their behavior to fit, possibility of management changes during the experimental period, and reasons for call light variations for the units was uncertain. Synthesis Methods: Samples and Data that did not meet the criteria were eliminated
Participants: 28 Emergency departments nationwide. Randomized samples. Characteristics and demographic data of each ED were collected. Data collected were categorized. Three types of rounding protocols established and implemented for 30 days. Study Appraisal: Eligible participants - 28; 10 ED perform 30-minutes rounding (36%), 9 performed 1-hour rounding (32%), and 9 performed 1-hour rounding with IPC (32%); overall result: positive changes.
Interview and survey. Sample consists of 28 patients pre-study and post-study
Interview and questionnaire; participants = 64 -equally divided into two groups; no exclusion reported.
Structured intervention - "Self-study pain management module". Pre-intervention and post-intervention outcome was used to evaluate the effectiveness of the tool.
Discharged patients were contacted to assess care provided during their hospitalization focusing on pain management. Interdisciplinary team was utilized in the study.
Convenience sampling method was used for both patients and chart auditing. Patient sample = 50, nurses sample = 93, chart audit for documentation = 50. Pain education conducted with the nurses. Postal board displayed in the unit for reminder. Validity and reliability of scale used to assess pain was established.
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Primary Outcome Measures and Results
Reduced patient use of the call light, reduced patient falls, and increased patient satisfaction. Eight hospitals (19 units) were excluded from analysis for poor reliability and validity of data collection; hospitals and units with rounding logs revealing more than 5% of data elements missing were excluded.
Patient satisfaction for overall care increased significantly. Measurement was done by comparing the baseline prior to the study and the outcome of the study.
"Patient survey indicates very little difference between the baseline pre-implementation and the post-implementation."
"There were no statistically significant differences in satisfaction. Perceived Cultural Competency Measure was used to measure the patients' perceptions of cultural competency of physicians. Patients that received the pamphlet reported finding the brochure helpful."
Significant improvement over time in cognitive knowledge
Scores from patients’ assessment of their care during hospitalization was analyzed to measure the outcome. Patient satisfaction scores improved.
Improvement in patient assessment, patient satisfaction, and nursing knowledge.
Author Conclusions/ Implications of Key Findings
Authors concluded that the findings are generalizable to the majority of U.S. Hospitals. Call light use decreases during the experimental period, patient satisfaction increased during the rounding protocol, and patient falls significantly reduced.
Rounding in the ED reception and treatment areas is effective and improves outcomes. Further research was recommended as a determinant for optimal design for rounding consideration for all shifts in Eds, seek ways to effectively communicate delays to patients, and investigate how to integrate rounding with physician activities. Implications: Lack of communication of delay, health status and treatment.
The author concluded that post-implementation indicated that there was a statistically significant improvement as a result of the Patient Service Partner (PSP) program. Nurses reported having more time for patient education, patient needs, answering patient question, providing high quality of care, and able to complete their paper work. However, the author indicated that the nurses were concerned and apprehensive about the use of PSP due to lack of trust, and a perception of inadequate preparation for delegation.
The authors concluded that implementation of the Ask Me 3 pamphlet has the potential to improve health care behaviors and health outcomes and may ultimately lead to a reduction in health care disparities.
"The findings from this pilot study demonstrated an improvement in the clinical pain management practices of nurses in one institution following the implementation of a structured intervention.
"The commitment to better pain management through an interdisciplinary team has improved patient satisfaction." Staff education need to be continued.
Authors indicates the need to continue quality improvement in order to maintain increase in patient satisfaction and nursing knowledge; inclusion of the other healthcare supports such as pharmacists, physicians, and others in the education sessions and survey was recommended. Authors emphasized that despite the improvement, the need to continue working on maintaining the increase in patient satisfaction is imperative.
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Strengths/ Limitations
Study method was valid, expected result was achieved, but bias exist in the staff adherence to the rounding protocol and survey was based on hospital vendors' data. Limitation include experimental design used (quasi-experimental design); researcher did not know all the factors each hospital use in their assignments, and possibility of inequivalent group.
Strengths: Supportive literature review and previous positive studies. Limitation: Further study is necessary to determine if rounding improves patient care as well as the best tactic for communicating delays to patients. Small sample size.
There is no indication of significant strength in this study except for the drive for improvement, cost-containment, and to avoid stagnation. Otherwise, substantial limitation could be noticed. The study was conducted in an environment that already has a high level of patient satisfaction based on the pre-implementation data, therefore, its generalization is limited; no indication of previous studies to compare with.
The study is easily implemented and cost less. Limitation include: small sample, focusing on low income people therefore generalization is hindered, absence of an independence verification of the patient's report and utilization of the pamphlet, and participants were not randomly selected.
"Strength: "Finding was congruent with the literature, which advocates the necessity of developing institutional programs for improving pain management." Limitation: Utilization of convenience samples, which limit generalization of the study; lack of sample match; lack of structured evaluation data regarding the pain management practices by the nurses before the structure intervention.
The strength is the interdisciplinary team utilized, which leads to a favorable outcome. Limitation includes undisclosed number of sample, which may cause bias as to the validity or generalization of the study.
Per the authors, strong patient response and nurse’s cooperation benefited the study. Limitation includes the use of convenience samples, limited education sessions, other healthcare providers such as the physicians, pharmacists, and support team were not included in the study.
Funding Source
The Studer Group funded the time and travel of the Alliance for Health Care Research staff involve in the study. Each participating hospital funded the costs directly related to the study.
Funding provided by the Studer Group
The study was funded by two individuals from St Luke's Hospital, Cedar Rapids, Iowa, but no financial support was specifically indicated.
Funding source was not indicated in this article.
Funding for this study was not listed
No source of funding disclosed in the article.
Source of funding was not indicated in this article.
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Comments
This is a very interesting study that despite its limitation can produce favorable results if properly implemented. It is obvious that it may be difficult for management to enforce the hourly or two-hourly rounding, or for the staff to persistently practice this intervention, however, it appear to be a viable practice that could bring a revolution to the taunting negative report of patient satisfaction in many hospital today. An attempt to find a solution to the issue of patient satisfaction is the focus of my project; this article is filled with elements that could be experimented to further confirm that hourly rounding or two hourly rounding could help with the issue of patient satisfaction.
This study exhibit another example of how hourly rounds could positively influence patient's perception about their care. Persistent application of the intervention is the key to achieving a continuous increase in patient satisfaction, patient safety, and reduction in length of stay. Further evaluation of the effectiveness of hourly rounding, and utilizing communication tools, is the focus of my project.
Although this is an old article with single experimental study, however, it is similar to an intervention that I personally formulated, which may be incorporated in my project. The outcome of the study yielded very little or no difference from the base outline, however, it has a potential of saving costs due to the integration of multiple discipline into one. It could also lead to nursing staff satisfaction because it creates room for more interaction with their patient and more time for patient education.
Although this article focused on physician communication with patients and patients' satisfaction and perception, it is obvious that application of this study in nursing communication with patient could produce patient's positive perception of their care as well. Encouraging patient to ask questions and verification of whether patient understand instructions and education via this type of tools (written questions/pamphlets) could also produce high patient satisfaction report.
Although this study did not have much reliability, its outcome indicated that the intervention could be effective. However, further study may be necessary to determine its generalization to other areas of similar structure of care. Improved 'communication with nurses' could be instrumentally valuable in this area.
This article was written by my mentor (Heather Chung) in collaboration with Dr. Nguyen, PH (a pharmacist) during her Doctorate program in 2005. Interestingly, pain management is one of the required core for meeting patient satisfaction; with a rigorous intervention the outcome was favorable. Again, effective communication could be very helpful in meeting this requirement.
According to the authors and other research findings, pain is considered as one of the major contributors to patient's satisfaction/dissatisfaction. Thus, pain management is a crucial part of the patient care. Nurses, physicians, and other providers need to communicate effectively with the patient as per what is being done to control their pain. This study indicates that using pain scale effectively may increase patient satisfaction. Additionally, educating the staff/nurses on effective communication is vitally needed to help the patient understand their care plan, and thereby increasing patients' satisfaction.
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Article Title and Journal
‘Caring for' behaviors that indicate to patients that nurses 'care about' them. Journal of Advanced Nursing Vol.60 (2), 146-153.
A critical review of patient satisfaction. Leadership in Health Services, Vol. 22(1).
Predictors of Patient Satisfaction with Inpatient Hospital Nursing Care. Research in Nursing and Health, Vol.27, 254-268.
Nursing: A key to patient satisfaction. Health Affairs, Vol.28 (4).
Intrusion and confusion - the impact of medication and health professionals after acute myocardial infarction. European Journal of Cardiovascular Nursing, Vol. 4, 153-159.
Patient perceptions regarding electronic prescriptions: is the geriatric patient ready? Journal of the American Geriatrics Society, Vol. 55(8),1254-9
Nurses' reported influence on the prescription and use of medication. International Nursing Review, Vol. 57, 92-97.
Author/Year
Amanda Henderson, Mary Ann an Eps, Kate Pearson, Catherine James, Peter Henderson, & Yvonne Osborne (2007).
Liz Gill and Lesley white (2009).
June H. Larrabee, C. Lynne Ostrow, Mary Lynne Withrow, Michelle A. Janney, Jr., Gerald R. Hobbs, Christopher Burant (2004).
Ann Kutney-Lee, Matthew D. McHugh, Douglas M. Sloane, Jeanie P. Cimiotti, Linda Flynn, Donna Felber Neff, and Linda H. Aiken (2009).
Mona From Attebring, Johan Herlitz, and Inger Ekman (2005).
Lapaine, K.L., Dube, C., Schneider, K.L., Quilliam, B.J. (2007)
Jutel, A., & Menkes, D.B. (2010)
Database and Keywords
Database: Medline. Keywords: Caring, empirical research report, interactions, nurses observation, patients survey
Database: Emerald. Keywords: Patients satisfaction, Health services, Quality management, Customer satisfaction.
CINAHL. Keywords: patient satisfaction; caring, nurse-patient relations; cooperative behavior; job satisfaction; quality of health care.
LexisNexis Academic data base. Keyword: Patient satisfaction.
Academic Search Premier. Keywords: Myocardial infarction; Secondary prevention; Adherence; Patients' experiences.
CINAHL. Keywords: e-prescribing; geriatrics; elderly; ambulatory setting; medication; communication.
CINAHL. Database: Marketing, Education, Nursing, Pharmaceuticals, Staff Development.
Research Design
Qualitative design with descriptive statistics. Meta-analyses
Predictive non-experimental study/Meta-analysis
Cross-sectional design
Qualitative design.
Cross-sectional
Single experiment/Survey/Questionnaire/Qualitative.
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Level of Evidence Level IIIB Level I Level I level IIIC Level IIIA Level IIIB Level IIIC
Study Aim/Purpose
"To explore what constitutes nurse-patient interactions and to ascertain patients' perceptions of these interactions"
"To review the patient satisfaction literature, specifically meta-analysis, which critically analyses its theory"
"To investigate the influence of registered nurse (RN) job satisfaction, context of care, structure of care, patient-perceived nurse caring, and patient characteristics on patient satisfaction with inpatient hospital nursing care in an academic medical center..."
"To evaluate the relationship between the nurse work environment and patient satisfaction."
To explore patients' experiences of secondary prevention after a first AMI.
"To evaluate the extent to which electronic prescribing (e-prescribing) alters communication about medication use between geriatric patients and their clinicians, as well as geriatric patients' perceptions regarding e-prescribing."
"To identify the activities senior nurses’ report undertaking that may influence the prescription and use of medicines."
Population Studied/Sample Size/Criteria/ Power
Inpatient in an acute hospital and the nurses. Patient Sample size was 35 with diagnosis of heart failure, myocardial infarction, respiratory failure, dementia, falls, cholecystitis, pneumonia, hypertension, Parkinson's, metastatic cancer, hysterectomy, cystoscopy and urethral obstruction.
This is a metal analysis of literature review study. It focuses on refuting the believe that patient satisfaction depends of quality of care.
Inpatient (N = 362), RN (N = 90) recruited from two medical units, two surgical units, and three intensive care step-down units. Criteria for inclusion: patient must be 18 years or older, speak and read English, no psychiatric issue, and admitted in one of the units being utilized for the study for at least 24hour. Participating nurse must be an employee for at least three months. P < 0.05.
All acute care hospitals in California, Pennsylvania, New Jersey, and Florida that (1) reported HCAHPS data to the CMS for the first public release period (October 20006-June 2007); had structural characteristics reported in the 2005 AHA Annual Survey; and (3) had nurses who responded to the University of Pennsylvania Multi-State Nursing Outcomes Study. 430 hospitals participated, Final sample of nurses 20,984. p<0.05.
Population: Men and women ages 34-79. Sample: 20 patients. Criteria: No previous treatment for cardiovascular disease. No power indicated in the study.
Thirty-five physician practices in six states using e-prescribing. 244 convenience sample of patients aged 65 and older.
Senior nurses (charge nurses, nurse educators, and patient educators), n = 100. Excluded from the survey are nurses who did not have individual mail box, and did not use their email address.
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Methods/Study Appraisal/ Synthesis Methods
Convenience randomly selected sample was used. "Twelve observation sessions of 4-hour duration" was implemented and carried out by two observers. Data collected was analyzed and arrived at a positive result.
A meta-analysis literature review, sample size was not clear; critique and analyses various studies and their findings.
Predictive non-experimental study using convenience sample of inpatient and nurses in the hospital medical, surgical, and intensive care step-down units. Data was collected for six and a half months. "Descriptive statistics were computed, Pearson correlations were used to estimate relations among patient satisfaction and candidate predictors."
Methods: Survey and questionnaires. Study appraisal: 430 acute care hospitals, 20,984 nurses, Follow-up with incentives were used to encourage nurses' participation in the survey.
Study was conducted in an outpatient clinical setting on patients that experienced Myocardial Infarction for the first time, and visiting the cardiac preventive nurse during March to September 2002. Patients that are unable to communicate due to stroke or dementia or unable to speak Swedish, and had undergone by-pass surgery were excluded from the study.
Voluntary survey was utilized. "Participants were asked to fill the survey anonymously and mail it in a prepaid envelop or drop it in a prepared box in the physician's office; cross-tabulation were then applied."
A parallel web-based and paper-based survey of senior registered nurses was utilized. 100 senior registered nurses were surveyed.
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Primary Outcome Measures and Results
Nurse-patients interaction indicated that they care for their patients. Management of activities of daily living (ADL) routinely, and explaining technical/medical aspects of patient care give the patient a positive concept of "professional knowledge of nurses."
The study indicated that "the construct has little standardization, low reliability and uncertain validity."
"Variables significantly and positively correlated (p<.05) with patient satisfaction were, in descending order of the magnitude of the relationship. Questionnaire, patient-perceived nurse caring, self-reported health status, quality of life, and patient reading ability" were utilized to measure the result." "There was empirical evidence of a strong relationship between patient satisfaction and patient-perceived nurse caring, and a small significant direct influence of RN/MD collaboration on patient satisfaction."
"Most hospitals need improvement in the areas that are important to patients. Patient-to-nurse ratios in hospitals affect patient satisfactions. Improving nurse work environments in hospitals could result in improved patient outcomes including better patient experiences."
The impact of medication - dealing with symptoms related to the medication, feeling intruded upon, feeling safe; and the impact of healthcare professionals - receiving conflicting information, wanting reassurance, experiencing the period after discharge as uncertain and precarious.
"Patients who reported having e-prescriptions were more likely to feel favorably toward the electronic method, whereas, most of those who reported never receiving e-prescriptions preferred paper prescriptions."
2% of nurses had prescribing rights, 70% reported recommending treatments to the prescribing doctors, 79% stated they provided advice to patients about over-the-counter medications, and77% participated in the development of guidelines or policies that include the use of medications. All nurses in this sample reported influencing the prescription of medicines in one way or the other.
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Author Conclusions/ Implications of Key Findings
"Findings suggest that patients believe that caring is demonstrated when nurses respond to specific requests. Patient satisfaction with the service is more likely to be improved if nurses can readily adapt their work to accommodate patients' requests or, alternatively, communicate why these requests cannot be immediately addressed.
The author considered the use of patient satisfaction as the ultimate measurement of quality of care is invalid and unreliable.
There was a significant relationship between patient satisfaction and patient-perceived nurses caring. RN/MD collaboration may also have influence in patient satisfaction.
Additional research on the impact of nursing on patient satisfaction is needed when more hospitals are reporting HCAHPS results. Implications: Patients' satisfaction scores are higher in hospitals where nurses practice in better work environments or with more favorable patient-to-nurse ratios. Improving nurses' work environments including nurse staffing, may improve the patient experience and quality of care.
Issues related to the patients' medication and to the health care professionals had a significant impact on their life after discharge.
E-prescription may enhance communication between geriatric patients and their clinicians. Geriatric patients may require more education to appreciate the value of e-prescribing.
The author concluded that the study confirm that there are many ways in which nurses can potentially influence the prescription of medications, even when they don't prescribe themselves. This study indicates that nurses’ involvement in the promotion and prescription of medication is very important; it would encourage compliance and effective outcome. Nurses have a central role in monitoring the prescription decisions of doctors; they play a major role in keeping medication errors to a minimum (Castledine, 2006). Exploration of nurses relationship to the pharmaceutical companies by the researchers was recommended
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Strengths/ Limitations
Strength: sample was randomly selected. Limitation: Convenience sample selection may cause bias and generalization of the study may be limited to similar environment; interaction was not followed through the patients' admission period.
It appears that this study' outcome could be valid; more study may be needed to support the study. Many literatures were reviewed according to the authors, but few were referenced as a supportive measure of the outcome of this study.
The authors of this study uses convenience samples of patients and nurses, therefore decreased the reliability of the study and may not be generalized.
Strength: Large number of samples; nursing was strongly associated with patient satisfaction measurements. Limitation: Utilization of cross-sectional design, which did not reveal the causation; the HCAHPS data are limited in the degree to which they explore satisfaction with nursing care.
The study was conducted with a small sample, therefore, generalization is limited.
Limitation: The authors indicated that the physicians recruited for the study were not randomly selected; possibility that participants may not be representative of all clinicians; selecting a convenience sample which may not be generalized representation of the geriatric population; result of the survey may be overly affirmed due to possibility of bias.
Small scale study, small sample, non-randomize selection of samples which may hinder generalization of the study.
Funding Source
Queensland Nursing Council
No specific sources of funding were indicated.
Contract grant sponsors: The John F. Brick Enhancing Patient Care Grant Program, West Virginia University Hospitals; the Nursing Division of West Virginia University Hospitals; and the West Virginia University School of Nursing.
The study was funded by grants from the National Institutes of Health, National Institute of Nursing Research; AMN Healthcare, Inc., and the Robert Wood Johnson Foundation
Funded by grants from The Local Research and Development department for Gothenburg and Southern Bohuslan, Swedish Heart and Lung foundation and Vardalstifelsen.
SureScripts - an adjunct to a grant entitled "Maximizing effectiveness of e-prescribing between physicians and community pharmacies" funded by Agency for Healthcare Research and Quality Collaborative Agreement.
Sources of funding were not disclosed in this article.
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Comments
This study indicates that communication is the key to winning patients' positive perception toward nurses’ interaction. If patients are effectively informed of their care plans, it would be easier for them to adjust or comply with the treatment regimen. Hence, promoting speeding recovery and less length of stay, this could eventually lead to patient satisfaction. However, "getting to know you" and "translating model is an important area that all healthcare provider need to adopt in order to show the patients that 'we care'.
This I an interesting study that may need further works to proof the validity of its outcome. I choose to review this article because it is diametrically opposed to the use of patient satisfaction as a base for measuring quality of care. Since the focus of my project is to improve patient-nurse interaction and communication in order to satisfy patients, it will not be surprising to realize down the road that we can never satisfy most of our patients due to their individual perception of care. It is evident that some patient will never be satisfied regardless of how well they have been cared for. However, improved 'communication with nurses' can greatly help in satisfying those type of patients.
This test, though not generalizable, revealed an important issue in patient satisfaction that is nurses may be unsatisfied with their job, which may be linked to why nurse-patient interactions were not impressive sometimes. I did not see this point emphasized so much in the other literatures that I had reviewed so far. The authors also indicated that nurses' dissatisfaction with their job is also linked to management strategies. This two areas may need to be dealt with first before quality of care can be tied to patient satisfaction.
Although, this study may require further research, it is obvious that nurse-to-patient ratio, and nurses' satisfaction of their work environment are the core of patient satisfaction. Shortage of nurses and efforts to contain cost could be an obstacle to solving the issue of nurses satisfaction and work environment; however, it appear that the ultimate solution is improvement in nursing care, and for the hospitals to achieve this, they would need to gain nurses satisfaction and improve their work environment.
This study reveals how the patients feel about the health care professional approach to their situation. It gave insight into why patient satisfaction has been a struggle for the hospitals and outpatient clinics. Based on the outcome of this study, patients’ satisfaction was hindered as related to medication and discharge experience. In essence, the patients expect thorough and accurate instructions from the healthcare professionals. Hence, nurses may need education on how to effectively communicate with their patients.
It may take time for some people to get acquainted to electronic transactions; however, the most important thing that everyone needs to remember is its efficiency and the focus on safety and reduction in medication error. So far, some of the technology that has been invented in the last few years regarding safe delivery of healthcare has proved successful; a good example is the armband scan prior to administration of medication to inpatients. Based on reports from the experts, medication errors have been dramatically reduced since the new technology has been adopted. With persistent education, people would eventually accept the e-prescription; we will have to wait to see its effectiveness as time goes on.
This article may appear focusing on pharmaceutical company's techniques and various ways of presenting their products and its effect on medication prescriptions, however, its direct/indirect association with nurses and patients' opinion about prescription is obvious. The study emphasizes the important role and influence that nurses have on medication prescription and how it affects the end user's (the patients) and the expected outcome. This indicates that nurses communication skills need to be sharpened, and education one of the way to accomplish the goal.
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Article Title and Journal
Registered nurses' medication management of elderly in aged care facilities. International Council of Nurses.
Impact of barcode medication administration technology on how nurses spend their time providing patient care. Journal of Nursing Administration, Vol. 38(12), 541-9.
Impact of a brief intervention on patient communication and barriers to pain management results from a randomized controlled trial. Science Direct: Patient Education and Counseling, Vol. 81, 79-86.
Communication and teamwork in patient care: How much can we learn from aviation? Journal of Obstetric, Gynecologic & Neonatal Nursing, Vol. 35(4), 538-46.
Medication Communication: a concept analysis. Journal of Advanced Nursing, Vol.66 (4):933-43
Proactive patient rounding to increase customer service and satisfaction on an orthopedic unit. Orthopedic Nursing, Vol. 27(4): 233-42.
Patient-reported outcome measures and how they are used. Nursing Older People, Vol. 23(1):31-6.
Author/Year
Lim, L.M., Chiu, L.H.,
Dohrmann, J., & Tan, K.L.
(2010).
Poon, E.G., Keohane, C.A, Bane, A., Featherstone, E., Hays, B.S., Dervan, A., Woofl, S., Hayes, J., Newmark, L.P., Gandhi, T. K. (2008)
Smith, M.Y., DuHamel, K.N., Egert, J., & Winkel, G. (2010).
Lyndon, A. (2006)
Manias, E. (2009)
Tea, C., Ellison, M., Feghali, F. (2008).
Palfreyman, S. (2011)
Database and Keywords
CINAHL. Adverse Drug Reactions, Aged Care, Continuing Education, Medication Management, Pharmacology, RN's Knowledge
CIHAHL/OVID, Bar Coding, Medication Systems, Patient Safety, Work Redesign
CINAHL. Pain, Patient Attitudes, Patient Education, Patient satisfaction.
CINAHL/PubMed. Communication, Team, Patient satisfaction, Patient safety.
CINAHL. Communication, medication management, nursing patient engagement, patient safety, quality of care.
Ovid Full Text. Patient satisfaction, Patient Rounding, Hourly Rounding.
CINAHL. Patient satisfaction, quality of care, quality of life.
Research Design
Quasi-experimental, non-randomized study/Qualitative
Time-motion Study/Qualitative.
Randomized control trial/Quantitative.
Systematic Literature Review/Qualitative.
Literature Review/Qualitative
Literature review/Qualitative non-randomized experiment Qualitative
Level of Evidence Level IIIC Level IIIA Level I Level IV Level IV Level IV Level I
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Study Aim/Purpose
"To examine Registered Nurses' knowledge of medication management and Adverse Drug Reaction (ADR) in the elderly in aged care facilities; evaluate an education program to increase pharmacology knowledge and prevent ADRs in elderly; and develop a learning program with a view to extending provision if successful."
"To evaluate the impact of Barcode Medication Administration on nursing workflow."
"To examine the impact of a brief pain communication/education intervention on patient outcomes in breast cancer."
"To identify evidence on the role of assertiveness and teamwork and the application of aviation industry techniques to improve patient safety for inpatient obstetric care."
"To analyze the concept of medication communication with a particular focus on how it applies to nursing."
To increase customer service and satisfaction.
"To provide nurses with information and advice about resources to increase their knowledge of Patient-Reported Outcome Measures (PROMs)" and its use.
Population Studied/Sample Size/Criteria/ Power
Targeted Registered Nurses working in a residential aged care facilities and involved with the administration and management of medication. Samples pre-test = 58, post-test = 40, attritions = 18. The Registered Nurses participated voluntarily with the assurance that their identity would be anonymous. P < 0.001.
37Nursing Units (surgical, medical, and critical care units) in a 735-bed hospital located in a tertiary academic medical center, with 2800 nurses, job status ranging from full-time to per diem, "treat approximately 45,000 patients annually." 116 observations were conducted with 182 nurses. P = .20).
89 female with breast cancer and persistent pain, randomly assigned to either 30minutes in-person pain education/communication intervention or control condition, followed for 12 weeks. Exclusion: pain symptom below frequency, medical appointments further than 3 months apart, not fluent in English or Spanish, no active breast cancer, too ill, and no medical appointment. For intervention P =0.04, Communication P = 0.540.
Pilots and Nurses. A total of 13 studies - 5 studies of teamwork, communication, and safety attitudes in aviation; 2 studies comparing these factors in aviation and healthcare; and 6 studies of assertive behavior and decision making by nurses. Studies lacking methodological rigor or focusing on medication errors and deviant behavior were excluded.
Population focus: Nursing. Sample: 43 studies. Criteria: Papers published in English and focused on medication communication. No power analysis.
Extensive literature review. 113 inpatient interviewed to determine what "timely response" means to them. P <.0001
Population: Older adult. Sample: No specific number of individual indicated. Criteria: no criteria. No power analysis.
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Methods/Study Appraisal/ Synthesis Methods
Pre-test and Post questionnaire was utilized. The questionnaire was divided into two sessions, the first relates to demographic data, and the second were multiple choice questions focuses on knowledge, and true or false statement questions. Reliability and Validity of the questionnaire was assessed prior to administering the tests; in-services in form of educational program were also given; the in-services and questionnaire were performed in the same manner in the seven facilities that participate in the study.
Direct observation and time-motion study was utilized. Primary outcome was obtained by comparing pre-barcode medication administration and post-barcode mediation administration observation applying the Wilcoxon ranked-sum test, which indicates non-significant drop in the proportion of time nurses spent on activities related to medication administration.
In-person education/communication intervention. Participants were randomly assigned to either experimental or control group, and followed-up for 12 months.
Literature Review, which include revision of 13 studies - 5 studies of teamwork, communication, and safety attitudes in aviation; 2 studies comparing these factors in aviation and health care; and 6 studies of assertive behavior and decision making by nurses. Pilot attitudes reveals effective performance attributable to behavior-based training to improve team performance, while nursing knowledge was inconsistently assessed in decision making. Findings regarding nurse assertiveness were mixed.
Literature review. Publications (in English) from January 1988 to June 2009 were selectively reviewed.
Logistic regression techniques. Questionnaire and interview. A Model was developed for patient rounding. Rounding logs were developed and utilized by the staff by following the guideline.
Non-specific; author focuses on information and advice for nurses and other healthcare providers.
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Primary Outcome Measures and Results
Most participants indicated "clearer picture regarding Adverse Drug Reactions and the risks of drug-drug reactions associated with polypharmacy in the elderly." Pre and post-test questionnaire was utilized as the measurement process. "Statistically, the overall result showed a high significant difference in the RNs" knowledge."
"Non-significant DROM in the proportion of time that nurses spent on medication administration-related activities."
"Patients with lower barrier scores reported less distress and better emotional well-being. Patients who scored higher in active communication reported fewer barriers and better pain relief. Individuals who perceived their physicians as being more receptive reported better pain management while those who perceived their physicians as being both more receptive and facilitative were more satisfied with their health care."
Pilot attitudes indicate effective performance in interpersonal interaction, which is attributed to "behavior-based training". Accessing nursing knowledge was considered inconsistent regarding decision making. Findings regarding nurse assertiveness were mixed.
No explicit use of the concept of medication communication. The concepts are already in use, but under-developed. Other outcomes: Attributes of medication communication; antecedents of communication in medication management; and what open communication mean in regards to medication communication.
Result indicated a significant improvement in patient satisfaction in the areas such as: timely response, staff anticipating needs, and hourly rounds. Chi square tests with p<.0001 was utilized.
PROMs questionnaire is generalized; older people do not benefit from the tool because their specific needs are not included in the measurement, or due to their deteriorating health status.
Author Conclusions/ Implications of Key Findings
Revelation of "an area of concern related to the lack of knowledge in medication management among RNs caring for the elderly residents in aged care facilities. Authors indicated that the study cannot be generalized due to the small of sample. A further study with a larger sample is needed. Overall result statistically indicates high significant differences in the RNs knowledge.
"A well-designed Bar Code Medication Administration (BCMA) system did not increase the amount of time that nurses spent on medication administration activities. Barcode medication technology likely streamlined activities for nurses, allowing them more time for other professional activities." Further study was suggested.
A brief education/communication intervention reduced patients' barriers to pain management but did not impact other patient outcomes. The authors emphasized that "improvement in pain outcome may be achieved by addressing patients' perception regarding pain, and emphasizing a receptive and responsive communication style."
"Adopting outside concept of training does not have significant impact on perinatal safety without an examination of contextual experiences of nurses and other health care providers in working to prevent patient harm."
The concept analysis could be utilized by nurses as a guidance to help them understand the implication of medication communication and its positive effect on patient safety.
Implementation of the “I Care Rounding model” helps the nurses to organize their time in a way that allow them to meet their patients' need, thus increasing patient satisfaction.
Consideration need to be given to health and cognitive impairment when developing this measuring tool for older adult.
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Strengths/ Limitations
The strength appears to be in the educational program and the pre and post-tests. The limitations falls on the low samples, non-randomized, result is not generalizable, further study is required.
Before-and-after study, which could create a confusing result. Observed nurses' workflow may be difference as a result of the awareness of the observation. Result did not reflect the initial learning curve for post-observation. Computer literacy was not assessed. "Time-motion study does not allow the assessment of the quality" of nurse-patient interaction.
This is a randomized study with control (n=42) and experimental (n=47) group. Although the sample size was not large enough, the study was well organized. An effective tailored approach was utilized. Limitation include higher barrier score which did not predict better pain management; author indicate discrepancy between findings in this study and previous research; patient self-report of medication usage and majority of their samples are considered low socio-economic group.
The sample was small, limited to only 13 studies. Further study is needed; nursing attitude alone should not be the main determinant of patient safety, and other support care personnel need to be considered.
Limitation was not clearly discussed in this article except that further study is required to measure medication communication in the real practice. Also, the outcome of the study was not clearly identified.
Strength: The "I Care Rounding model serves as a guide for the staff to effectively meet the requirement. Limitation: There is no assurance that all staff utilized this model accordingly.
PROMs questionnaires are mostly generic according to the author's finding.
Funding Source
Grant from the Health Career International Pty. Ltd. Melbourne, Australia.
Institutional review board at Partners Healthcare, Boston, Massachusetts; and RO1 grant from the Agency for Healthcare Research and Quality, Washington, District of Columbia.
American Cancer Society; Susan G. Komen Foundation; U.S. Army Medical Research and Materiel Command, Department of Defense.
No specific sources of funding were indicated.
Australian Research Council (Discovery grant).
No tie to any financial company or entity.
For this article there was no indication of source of funding.
60
Comments
Although this study is statistically not generalizable to other areas, with a further study, it is possible to indicate the relationship between RNs knowledge of medication management and communication regarding medication. Unless the nurses are well knowledgeable of the medications they administered to the patients it would be difficult for them to teach the patients on the mechanisms of the medications. Hence, in order to improve patients' satisfaction regarding medication, nurses need to be equipped with the pharmacokinetic/mechanism of medication and this could be achieved via educational programs.
This is an interesting study, but it appeared inaccurate based on the real-world experience as a nurse who has actually utilized barcoding medication administrative system. Based on other researches, barcoding decrease the occurrence of medication error, which is the main purpose of implementing this device; however it does not appear to have decrease time nurses spent during the application of this device. Nevertheless, the main focus in medication administration is safety regardless of how much time it may consume.
Pain is whatever the patient perceived pain is. This study touches on one of the major concerns of inpatients and one of the major areas that can drop the hospital's HCHAP score for patient satisfaction. Unless pain is well controlled, the individual cannot be pleased, which is why pain is considered number 5 vital sign. The authors focused on patients' barriers (e.g. misconception) to communicating pain; the main intervention is education, if nurses would persistently communicate and educate patients on what to expect for example, post-surgical procedure, patient might be able to adjust to his/her present situation and comply with the treatment regimen, which could lead to the expected patient outcome.
Communication and teamwork is one of the main anchors for effective healthcare delivery. However, it takes everyone involvement to prevent harm to the patients. The author emphasized this notion in the conclusion that other ancillary support needs to be examined to fully determine effective safety net for patients.
Medication communication is an essential element in patient care. The author emphasized the communication regarding medication among the stakeholder need to be open and each individual need to understand the concept wrapped in communication. As one of the focus in patient satisfaction, effective communication is indispensable regarding patient medication and safety.
Based on other research findings, hourly rounds has been considered one of the most recent tools implemented to address patient satisfaction, and the indication has been very positive. This study has a direct implication for many healthcare institutes that are struggling to meet the targets indicated by the Medicare/Medicaid Services. In order to fully integrate hourly rounding into nursing care, it is imperative that nurses are equipped with communication skills.
This article may not directly address patient satisfaction, but the tool (PROMs) could be a valuable instrument in determining how patients feel after discharge, or their concept of how well they were cared for during hospitalization. Also, the PROMs could help to address level of patient satisfaction in some other areas, particularly, nurses' communication skills.
61
Article Title and Journal
Is patient involvement during hospitalization for acute myocardial infarction associated with post-discharge treatment outcome? An exploratory study. Health Expectations, Vol. 13(2): 298-311.
Obtaining Information on Patient Satisfaction with Hospital Care: Mail Versus Telephone. Health Services Research, Vol. 19(3), pp. 291-306.
Does Doctor-Patient Communication Affect Patient Satisfaction with Hospital Care: Results of an Analysis with a Novel Instrumental Variable? Health Service Research, Vol. 43(5p1), p.1505-1519, 15p
Author/Year
Arnetz, J.E., Winblad, U. Hoglund, A.T., Lindahl, B., Spangberg, K., Wallentin, L., Wang, Y., Ager, J., Arnetz, B.B., (2010).
Walker, A.H. & Restuccia, J.D. (1984).
Clever, S.L., Lie, J., Levinson, W., Meltzer, D.O. (2009).
Database and Keywords
CINAHL/Wiley Online Library. Patient satisfaction, patient involvement, patient perceptions.
PubMed. Patient satisfaction, Information
Academic Search Premier. Keyword: Doctor-patient communication, patient satisfaction.
Research Design Self-administered questionnaire study. Cross-analysis/qualitative.
Methodological study/Qualitative method Qualitative
Level of Evidence Level I Level II
Level IIIC
62
Study Aim/Purpose
"To investigate whether patient involvement during hospitalization for acute myocardial infarction (MI) was associated with health and behavioral outcomes 6 - 10 weeks after hospital discharge."
"To develop a questionnaire useful in eliciting the perceptions of patients regarding their hospital care, to compare the methodological and substantive differences between a mail survey and a telephone survey of patients done approximately a week post discharge, and to develop methods allowing the questionnaire to be administered by an organization other than the hospital."
To determine relationship between physicians' communication behaviors and patients' overall satisfaction with hospital care.
Population Studied/Sample Size/Criteria/ Power
Population: Cardiac Patients first follow-up visit post hospitalization for MI. N = 591. Criteria: MI patient under age 75 and qualified for Secondary Prevention after Heart Intensive Care Admissions (SEPHIA). P<0.01
Discharged patient from the test hospital. "Systematic random sampling" was utilized in selecting sample of patient. Telephone survey sample = 525, responded = 355. Mail Survey sample = 296, response = 172. Criteria - Patient discharge from the test hospital. P < .05 or = .05
Inpatients/Discharged patient; Sample = 3,123. Only patients who were admitted to the hospital used for the study were eligible to be included in the study, and excluded were those patients discharged prior to being approached by the researcher, those that could not speech English, those with cognitive problem. P<.05
63
Methods/Study Appraisal/ Synthesis Methods
32 hospitals were invited to participate in the study, only 11 agreed to participate. Patients who participated were MI patients under the age of 75. Data collection lasted a year. Questionnaire with information about the study were given to each qualified patients on their first follow-up visit post discharged (6-10 weeks). 782 questionnaires were given out during the one year period, 652 were returned. 61 patients were eliminated because they were treated in non-participating hospitals, while 17 cases either had a duplicate code or no code. Final sample for the study was 591 patients. Psychometric analysis of the questionnaires indicated that they were valid and reliable. Only 449 samples were analyzed at the end of one year, 142 were lost to follow-up.
Methodological study - one out of every three discharged patient was selected for the study, which lasted four weeks. Each patient was given letter of explanation upon discharge, which describe purpose of the survey, and let them know that someone will call or they will receive a mail, and were assured of confidentiality. Participants were interviewed seven days after discharged
"Administrative records and post discharge survey data were utilized. Instrumental Variable method was utilized to measure the outcome.
64
Primary Outcome Measures and Results
"At the time of first follow-up visit 72% of patients had stopped smoking; 57% had achieved target level for systolic blood pressure; 72% had achieved target levels for LDL cholesterol; 46% had been regularly physically active; 82% were on ACE inhibitors or angiotensin blockers; and 53% had returned to work."
"An organization external to the hospital can economically conduct a patient satisfaction survey of a representative patient sample while ensuring confidentiality and producing potential useful results." Mail survey was preferred over the telephone survey" because it is cost effective, minimal "bias" and confidentiality can be assured.
"Primary outcome was patients' ratings of their overall satisfaction with hospital care, which ranges from 41.8 to 48.4 percent of 3,123 patients. Instrumental Variables (IV) method was used to measure the outcome;" "there was a significant positive relationship between overall satisfaction and overall ratings of attendings' communication behaviors."
Author Conclusions/ Implications of Key Findings
"While patient involvement ratings were related to some outcomes, this study indicates that involvement during hospitalization was not associated with MI patient health and behavior 6-10 weeks after hospital discharge." Further study is needed.
Both Telephone and mail method of the study has its pros and cons. The telephone survey was time consuming, could create bias per patient's reluctant to express any satisfaction; the advantage is the higher rates of response, easy to call participants multiple of times, and fast response. Mail survey cost less, confidential, less bias in the results, and interviewers were not needed, disadvantage include no control over the time of arrival of response, and a lower response rate. Survey conducted by an "external organization would enable" comparison among the hospitals.
Because "only 33% of the patients rated the physician communication satisfactory" indicates that "there is room for improvement."
65
Strengths/ Limitations
Several limitations were indicated in the study but few will be listed here: Approximately "one quarter of the questionnaire were lost to follow-up in the SEPHIA register", which may create bias. "Patient ratings of the involvement scales did not differ significantly between those included in the SEPHIA registry and those lost to follow-up." Patient responses to the questionnaire were made after hospital discharge and were thus retrospective, allowing room for recall bias." And the time of the first follow-up visit, when patients received the questionnaire, varied between hospitals, with patients responding in different phases of post-MI recovery."
The study appear to have serve well with the possibility of being able to compare hospitals' performance, but it also have a bias issue regarding the telephone survey.
The study "cannot determine whether other physician characteristics, such as technical behavior, may have influenced patients' ratings of both the physician's communication behaviors and their ratings of the care they received in the hospital." The samples were selected from one hospital, thus may hinder generalization of the result.
66
Funding Source
Research grant was from The Swedish Association of Local Authorities and Regions (SALAR), The Swedish Heart-Lung Foundation, The Swedish Heart and Lung Association, Swedish Skandia Life Group and Wayne State University. W.K. Kellogg Foundation
Grant given by University of Chicago Hospitals, Chicago, IL; the Charles E. Culpeper Foundation, New York, NY; the National Institute of Aging, Bethesda, MD; and the Robert Wood Johnson Foundation, Princeton, NJ.
Comments
Relating the outcome of this study to some of the outcome for patient satisfaction survey, it is possible to raise bias in the process of distributing questionnaire and analyzing responses because some of the patients were admitted for different diagnosis, thus, delivery of care may be slightly different. This survey turned out to be unfulfilling due to the several limitations indicated in the article; therefore, its application to addressing patient satisfaction may be inappropriate.
It appears this study was done to find a means of reducing hospitals overhead costs and at the same time attempting to collect data that could help determine patient satisfaction. The mail survey method could be utilized in my study, but small sample could be one of its limitation (N=53).
This study attempt to determine how physicians' communication with the patient is related to patient satisfaction. The result indicated that even a slight increase in the patients’ satisfaction in this area would significantly improve patients' care outcome. Thus, it appear both physicians and nurses effective communication with the patients could make a lot of difference in patients' healing and compliance with their treatment regimen, and thereby increase patients' satisfaction.
67
Appendix C
Logic Model Development for Patient Satisfaction: Communication with Nurses
Adapted from Zaccagnini, M.E., & White, K. W. (2011). A template for the DNP scholarly project. The Doctor of Nursing Practice Essentials: A New Model for Advanced Practice Nursing. Sudbury, MA: Jones and Bartlett.
Problem•The need to increase Patient Satisfaction score to a threshold or target score (77.4% to 78.4%)
Input•Nurses, Patient Care Assistants, Unit Secretaries, Education, Power Point, Oral Presentation, Video, Tools, Resources, Incentives, hourly rounding, management rounding
Activities
•Develop tools and implement evidence-based intervention with purposeful hourly rounding•Education & Data Collection•Visual aids (Video & Power Point)•Pre- & Post-intervention questionnaires
Output •Improved staff knowledge of effective communication and hourly rounding
Outcome•Improved staff level of knowledge, Improved staff communication skill, Patient satisfaction scores at the threshold or on target (77.4 to 78.4)
Impact•Improved staff Communication skill•Increased Patient Satisfaction•Full Reimbursement from the Medicare/Medicaid
Potential constraints
•Staff work schedule, staff resistance, Institution Research Counsel Committee & IRB approval process, Limited Resources, & Funds
68
Appendix D
Adapted from Zaccagnini, M.E., & White, K.W. (2011). The Doctor of Nursing Practice Essentials: A New Model for Advanced Practice Nursing. Sudbury, MA: Jones and Bartlett
•The need to increase Patient Satisfaction score to a threshold or target score (77.4% to78.4%)
Problem Issue
•Nurses, Patient Care Assistants, Unit Secretaries, Education, Power Point, Oral Presentation, Video, Tools, Resources, Incentives, hourly rounding, management rounding
Input •Develop tools and implement evidence-based intervention with purposeful hourly rounding
•Education & Data Collection•Visual aids (Video & Power Point)
•Pre- & Post-intervention questionnaires
Activities
•Improved staff knowledge of effective communication and hourly rounding
Output
•Improved level of knowledge, Improved staff communication skill, Patient satisfaction scores at the threshold or on target (77.4 to 78.4)
Outcome
•ImprovedCommunication skill
•Increased Patient Satisfaction
•Full Reimbursement
Impact
• Work schedule • Staff resistance • Institution Research
Council Committee & IRB approval process
• Resources, & Funds
Conceptual Diagram
69
Appendix E.1
Measurement Tool/Instrument
Communication Tool: Rounding Checklist Evaluation Tool
HOURLY ROUNDING DIRECTOR/MANAGER/EVALUATOR ROUNDING CHECKLIST
Date: Department: Evaluator: Yes No N/A Comments ACKNOWLEDGE/INTRODUCTION 1.Knock on door prior to entering 2.Use key words to introduce yourself [and your co-workers] 3.Smile and address them as “Mr. or Mrs.” and last name 4.Manage up your skill [or that of your co-workers] 5.Update White Board: Place name (MD, RN, PCA, HCT/SCA) DURATION 1.Explain hourly rounding upon admission [and daily] 2.Describe rounding schedule 3.Use key words “very good” care 4.Communicate when you will return EXPLAIN 1.Explain what you are doing as you complete MD ordered treatments, procedures, bed alarm on if applicable, etc.
2.Explain action & side-effects as you administer scheduled & PRN medications
ADDRESS THE 4Ps 1.Ask patient how is their pain 2.Ask patient if they are comfortable/need to be turned/position 3.Ask patient if they need to use the bathroom (potty) 4.Move items (placement) within reach (call light, phone, etc.) & offer PO
CLOSING [THANKS] 1.Thank the patient for chosen TMHS for his/her health care 2.Communicate when you will return every time you round 3.Ask “is there anything else I can do for you? I am pleased to care for you”
(Contents and formation of this figure was adapted from Studer Group (2011), hardwire the five fundamentals of service, and Tea, C., Ellison, M., & Feghali, F., (2008): Proactive patient rounding)
70
Appendix E.2
Measurement Tool/Instrument
HOURLY ROUNDING LOG Evaluation Tool Room & Bed Number: ____________ Date: ____________
(*PLEASE WRITE YOUR INITIALS LEGIBLY) Time Staff *Staff
Initial Actual Round
Time Activity Perform on Round (Indicate Y/N)
(All ‘No’ Requires a Comment) (Y = Yes, N = No)
Comments
7a- 8a
PCA ___Pain ___Potty ___Position ___Placement ___Asleep
8a- 9a
Nurse ___Pain ___Potty ___Position ___Placement ___Asleep
9a- 10a
PCA ___Pain ___Potty ___Position ___Placement ___Asleep
10a- 11a
Nurse ___Pain ___Potty ___Position ___Placement ___Asleep
11a- 12N
PCA ___Pain ___Potty ___Position ___Placement ___Asleep
12N- 1p
Nurse ___Pain ___Potty ___Position ___Placement ___Asleep
1p- 2p
PCA ___Pain ___Potty ___Position ___Placement ___Asleep
2p- 3p
Nurse ___Pain ___Potty ___Position ___Placement ___Asleep
3p- 4p
PCA ___Pain ___Potty ___Position ___Placement ___Asleep
4p- 5p
Nurse ___Pain ___Potty ___Position _ __Placement ___Asleep
5p- 6p
PCA ___Pain ___Potty ___Position ___Placement ___Asleep
6p- 7p
Nurse ___Pain ___Potty ___Position ___Placement ___Asleep
7p- 8p
PCA ___Pain ___Potty ___Position ___Placement ___Asleep
8p- 9p
Nurse ___Pain ___Potty ___Position ___Placement ___Asleep
9p- 10p
PCA ___Pain ___Potty ___Position ___Placement ___Asleep
10p 11p
Nurse ___Pain ___Potty ___Position ___Placement ___Asleep
12a 1a
PCA ___Pain ___Potty ___Position ___Placement ___Asleep
1a- 2a
Nurse ___Pain ___Potty ___Position ___Placement ___Asleep
2a- 3a
PCA ___Pain ___Potty ___Position ___Placement ___Asleep
3a- 4a
Nurse ___Pain ___Potty ___Position ___Placement ___Asleep
4a- 5a
PCA ___Pain ___Potty ___Position _ __Placement ___Asleep
5a- 6a
Nurse ___Pain ___Potty ___Position ___Placement ___Asleep
6a- 7a
PCA ___Pain ___Potty ___Position ___Placement ___Asleep
NURSES: ROUND ON EVEN HOURS PCA: ROUND ON ODD HOURS
(The contents of this figure were partially adapted from Woodward, J. L. (2009). Effect of rounding on patient satisfaction and patient safety on a medical-surgical unit)
71
Appendix E.3
Measurement Tool/Instrument
Hourly Rounding Pre- and Post-Intervention Questionnaire
Note: This is not a pass or fail questionnaire, it is simply a tool to help us evaluate the effectiveness of the hourly rounding. Please be honest in your responses.
1. List the 4ps. (Woodward, 2009)
a. ------------------------------ b. ------------------------------ c. ------------------------------ d. ------------------------------ (20points)
1. What does the acronym AIDET mean? (Struder Group, 2011) A ---------------------------------- I ---------------------------------- D ---------------------------------- E ----------------------------------
T ---------------------------------- (20points)
3. “Do you round routinely every 2 hours?” (Woodward, 2009, p. 203) 1) Never 2) sometimes 3) usually 4) Always (8point)
4. “If not always what is/are the barriers to completing routine rounds every 2 hours?” (Woodward, 2009, p.
203) a. Acuity of your patients b. Short of help c. Forget to round d. All of the above (20points)
5. “Do you address ALL of the 4 P’s (pain, potty, position, and placement/presence) while rounding and sign
the rounding sheet?” (Woodward, 2009, p. 203) 1) never 2) sometimes 3) usually 4) Always (8points)
6. “If not always, what is/are the barriers to addressing ALL 4 P’s while rounding?” (Woodward, 2009, p.
203) a. Forget to sign rounding sheet b. In a hurry c. Distracted d. All of the above (10points)
7. How would you assist Mr. J. become knowledgeable about his care?
a. Communicate what you will be doing b. Tell him what to expect c. Explain plan of care d. All of the above (10points)
8. List one area in this presentation you will always remember as you perform your hourly rounding. ---------------------------------------------- (4points)
72
Appendix E.4
Measurement Tool/Instrument
Demographic Data
1. How many years have you been practicing as a nurse/healthcare provider a. 0 – 5 years b. 6 – 10 years c. 11 – 15 years d. Over 15 years
2. How long have you been working this Medical Unit? a. 0 – 5 years b. 6 – 10 years c. 11 – 15 years d. Over 15 years
3. Gender: ( ) Male ( ) Female Age: ( ) 18 -30 ( ) 31-40 ( ) 41- 50 ( ) Over 50 (Please check one) Level of Education: ( ) High School ( ) Associate Degree ( ) BSN ( ) MSN ( ) Certifications (Please specify) __________________________ ( ) Other (Please specify) ________________________________ Job Designation: ( ) RN ( ) PCA ( ) US
73
Appendix E.5
Measurement Tool/Instrument
PATIENT SATISFACTION STAFF EDUCATION/INSERVICES DATE AND TIME
DATE DAY TIME Comment
02/06/2012
Monday
07:30am 10:30am 12:30pm 2:30pm 4:30pm
02/07/2012
Tuesday
7:30pm 10:30pm
02/08/2012
Wednesday
10:00am 12:00pm 2:00pm
02/09/2012
Thursday
2:00pm 5:00pm 7:30pm 10:30pm
02/12/2012
Sunday
7:30pm 10:30pm
02/14/2012
Tuesday
7:30pm 10:30pm
02/15/2012
Wednesday
10:00am 12:00pm 4:30pm
02/16/2012
Thursday
2:00pm 4:00pm 7:30pm 10:30pm
74
Appendix F.1 Project Implementation Timeline Chart 2012
Steps Jan. 2012
Feb. 2012
Feb. 2012
Mar. - April 2012 Comment
Step I
Pre-intervention phase - 2nd week of Jan.
to 4th week of Jan.
Step II
Intervention phase - 1st week of Feb.
to 3rd week
Step III
Post-intervention phase - 4th week of Feb. to 2nd week of March. Data analysis continued till April.
Step IV
Project Outcome conclusion phase
Chart developed from Capstone Project Timeline, Zaccagnini & White, 2011, p.475
75
Appendix F.2
CAPSTONE PROJECT TIMELINE 2011 - 2012
STEPS TIMELINE Step I Problem Recognition
Identify Need: The need to improve nurse-patient communication as related to patient satisfaction was identified based on the HCAHPS survey (Hospital Consumer Assessment of Healthcare System) Problem Statement: Based on the HCAHPS survey analysis, it was noted that patient satisfaction target goal was not met. Therefore it was concluded that an intervention should be developed and implemented to improve nurse-patients interaction. It was anticipated that the outcome would lead to an increase in patient satisfaction score. Literature Review: A rigorous search for related literature was conducted, which was expected to continue throughout the project for evidence-based information.
Target date of completion: May 1, 2011
Step II Needs Assessment Population: Registered Nurses (RN), Patient Care Assistants (PCA) and the Unit Secretaries (US) in an acute care hospital in the Houston Medical Center on a 29 bed medical unit. Identify sponsor and stakeholders Assess the organization as related to the project Evaluate available resources Identify desired outcomes Select team members Analyze cost and benefit Define the broadness of the project This section was a continuation from Spring 2011 Semester; some of the items was previously addressed . Target date of completion: May 30, 2011
Step III Goals, Objectives, & Mission Statement Goals: Identify clinical issue (Patient Satisfaction), Analyze the issue, develop evidence-based practice intervention, complete related literature review, implementation of intervention, comparison of the pre-intervention and post-intervention HCAHPS score, and measure the effect of the outcome. Process/Outcome objectives: Intervention and expected outcomes. Jean Watson’s Theory of Human Caring would be incorporated as related to this issue of patient satisfaction. Develop Mission Statement: Focusing on patient satisfaction. Target date of completion: June 18, 2011
Step IV Theoretical Underpinnings Theories to support project framework: Jean Watson’s Theory of Human Caring Target date of completion: June 27, 2011
Step V
Work Planning Project Proposal: Elaborate on the necessary changes that would benefit the population and the stakeholders in general. Indicate supporting theory or theories. Project management tools: Milestones – Timeline & Budget Target date of completion: July 18, 2011. This step was completed in Nov. 2011
76
Step VI Planning for Evaluation Development evaluation plan: This would include method of evaluation. Logic Model development Target date of completion: July 15, 2011
Step VII Implementation Institutional Review Board (IRB) approval Threats and barriers – Review goals, objectives, and work plans. Identify possible hindrances. Monitoring implementation phase Project closure Target date of completion: August 28, 2011 Note: Target date was not accomplished due to IRB requirement that was in progress. This part was complete in March 2012
Step VIII Giving Meaning to the Data Descriptive data Target date of completion: April 29, 2012
Step IX Utilizing and Reporting Results Written dissemination Oral dissemination Electronic dissemination Target date of completion: April 29, 2012
Adapted from the DNP Project Process Model, Regis University (2010)
77
Appendix F.3 Capstone Project Timeline Chart 2011 - 20012
Steps January - May 2011
Jun-2011 Jul-2011
Aug 2011-Mar 2012 Sept 2011-Apri 2012 Comment
Step I
Step II
Step III
Step IV
Step V
Step VI
Step VII
Step VIII
Step IX
Chart Developed from Capstone Project Timeline
(Zaccagnini & White, 2011, p. 475)
78
Appendix G.1 Capstone Project Budget (Estimated)
Budget Items Estimated Cost $
Expenses Stationary: Binders Printing papers Manila Folders Pencils, Sticker notes Printer cartridge Photocopy Total Parking at clinical practice site Incentives for staff at Clinical practice site Statistician Transportation & gas Unforeseen Expenses
150 100
10 30
1,800 60
2,150
600 400
1,500 600 200
Total Estimated Project Budget 5,450
Appendix G.2
Principal Investigator’s Costs & Funds Items ($) Cost ($) Funds ($)
Funds Cash Loan Total Funds
1,000 2,500
3,500 Expenses Stationary: Binders ………………………………………… Printing papers ………………………………… Manila Folders ………………………………… Pencils, Sticker notes ………………………….. Printer cartridge ……………………………….. Photocopy ……………………………………... Parking at clinical practice site …………………… Incentives for staff at Clinical practice site (Pre-Intervention, Intervention phase, & Post-Intervention) ……………………………………… Statistician ………………………………………… Transportation & gas ………………………………
98 60
5 10
500 40
310
215 800 780
Total Available Fund 3,500 Total cost 2,818
Net Balance 682 Total Project Cost (Principal Investigator’s cost (2,818) + Indirect cost to the Hospital (1,900) =
$4,718
79
Appendix H
REGIS~ UNIVERSITY
October 20. 20 I 1
Clithy Oni 8735 Kcegans Forest Ln Houston. TX 77031
RF.: IRS II : 11-306
Dear Cathy:
ACad e mic Affai rs Acad em ic Gran's
IRB - REGIS UNIVERSITY
3333 RO\:ll$ 6oolevard. M_4 Den_. Co!o<aoo 80221-1099
303·453·4200 303-964-3647 FAX ....... te9'f_e<IV
Your application to the Regis IRB for your project "Patient Satisfaction : Communication with Nurses" was approved as exempt on October 18,2011.
Supponing reference information from the chair:" .. approved as an exempt study under 45CFR46.1 01 (b)(2) (survey research).
The designation of ·'exempt.·· means no further IRB review of this project. as it is currently designed, is needed_
If changes aTC made in the research plan that significantly alter the involvement of human subjects from Ihal which was approved in Ihe named application, the new research plan must be n:~ut,,"itt"u tu til" R"gi~ !RI3 rUI Ilppruv llL
Si",~~ Daniel ROYS~ Chair, Institutional Review Board
cc: Phyllis Graham-Dickerson, Ph.D.
A JESUIT UNIVERSITY
80
Appendix I.1
CITI Collaborative Institutional Training Initiative
Human Research Curriculum Completion Report Printed on 3/21/2012
Learner: Cathy Oni (username: ccao10) Institution: Regis University Contact Information 8735 Keegans Forest ln.
Houston, TX 77031 USA Department: Nursing Phone: 713-995-6053 Email: [email protected]
Social Behavioral Research Investigators and Key Personnel: Stage 1. Basic Course Passed on 06/13/11 (Ref # 6152260)
Required Modules Date
Completed
Introduction 06/09/11 no quiz
History and Ethical Principles - SBR 06/12/11 4/4 (100%)
The Regulations and The Social and Behavioral Sciences - SBR 06/12/11 5/5 (100%)
Assessing Risk in Social and Behavioral Sciences - SBR 06/12/11 5/5 (100%)
Informed Consent - SBR 06/12/11 5/5 (100%)
Privacy and Confidentiality - SBR 06/12/11 3/5 (60%)
Regis University 06/13/11 no quiz
For this Completion Report to be valid, the learner listed above must be affiliated with a CITI participating institution. Falsified information and unauthorized use of the CITI course site is unethical, and may be considered scientific misconduct by your institution.
Paul Braunschweiger Ph.D. Professor, University of Miami Director Office of Research Education CITI Course Coordinator
81
Appendix I.2
CITI Collaborative Institutional Training Initiative
Human Research Curriculum Completion Report Printed on 3/21/2012
Learner: Cathy Oni (username: ccao10) Institution: Methodist Hospital System - Houston, Texas Contact Information Department: Nursing
Phone: 713-995-6053 Email: [email protected]
Group 1 - Biomedical: Biomedical Investigators Stage 1. Basic Course Passed on 10/13/11 (Ref # 6863036)
Required Modules Date
Completed Score
Introduction 10/04/11 no quiz
History and Ethical Principles 10/04/11 6/6 (100%)
Basic Institutional Review Board (IRB) Regulations and Review Process 10/04/11 5/5 (100%)
Informed Consent 10/04/11 4/4 (100%)
Social and Behavioral Research for Biomedical Researchers 10/12/11 4/4 (100%)
Records-Based Research 10/12/11 2/2 (100%)
Genetic Research in Human Populations 10/12/11 2/2 (100%)
Research With Protected Populations - Vulnerable Subjects: An Overview 10/12/11 4/4 (100%)
Vulnerable Subjects - Research Involving Prisoners 10/12/11 4/4 (100%)
Vulnerable Subjects - Research Involving Children 10/12/11 3/3 (100%)
Vulnerable Subjects - Research Involving Pregnant Women, Human Fetuses, and Neonates 10/12/11 3/3 (100%)
Avoiding Group Harms: U.S. Research Perspectives 10/12/11 3/3 (100%)
FDA-Regulated Research 10/12/11 5/5 (100%)
Research and HIPAA Privacy Protections 10/13/11 5/5 (100%)
Conflicts of Interest in Research Involving Human Subjects 10/13/11 5/5 (100%)
The Methodist Hospital System 10/13/11 no quiz
For this Completion Report to be valid, the learner listed above must be affiliated with a CITI participating institution. Falsified information and unauthorized use of the CITI course site is unethical, and may be considered scientific misconduct by your institution.
Paul Braunschweiger Ph.D. Professor, University of Miami Director Office of Research Education CITI Course Coordinator
82
Appendix J
The Methodist Hospital 6565 Fmll\in Street, MGJ 11-018 Houstoll. Texas 77030
IRB Rcgis University 3333 Regis Blvd Denver, CO 80221-1099
December 19, 201 1
RE: Cathy OniPatiel!t ,xlfisfac.tion __ Communication wi th Nurses
Dear Regis IRa,
The purpose of this letter is to oonfinn The Methodist Hospita l participation in Patient Satisfaction: Communication with Nurses that Cathy Oni will be carrying out in our institution_ Further, The Methodist Hospita~has reviewed the protocol and deemed that it does not require IRE approvnl and accepts the review/judgment of the Regis IRB regarding the use of human subjccl~ in this projed.
-:;reIY~~;</ Ass~icfofNursing Kesean:b and Evidence-Based Practice
